Evaluation of a Novel Audit Tool for Medication Reconciliation at Hospital Discharge.

backgroundDischarge medication reconciliation (MedRec) is designed to reduce medication errors and inform patients and key postdischarge providers, but it has been difficult to implement routinely in Canadian hospitals.

objectivesTo evaluate and optimize a new discharge MedRec quality audit tool and to use it at 3 urban teaching hospitals.

methodsThe discharge MedRec quality audit tool, developed by the Canadian Patient Safety Institute and the Institute for Safe Medication Practices Canada, was assessed and modified to improve comprehensiveness, clarity, and quality. The modified tool was then used to evaluate the quality of the discharge MedRec process for adult patients discharged to home from the general internal medicine service at 3 academic hospitals. Postdischarge telephone interviews were conducted with consenting patients, their community pharmacists, and their family doctors.

resultsThe audit tool required modification to include aspects of admission MedRec, high-risk medication discrepancies, and direct communication of discharge MedRec to key follow-up providers. Thirty-five patients (mean age 67.7 years, standard deviation [SD] 18.0 years; 17 [49%] women), with a mean of 8.8 (SD 4.5) prescribed medications at discharge, participated in the discharge MedRec evaluation. Documentation of any discharge MedRec was found for only 1 patient (3%), and no discharge MedRec was carried out by pharmacists. Postdischarge follow-up interviews elicited major gaps in communication with community pharmacists and with family physicians, which could lead to serious medication errors.

conclusionsThe modified audit tool was useful for identifying gaps in the quality of discharge MedRec.