Volume: 8 Issue 11 [November 2025]

Article:The Impact of a Structured Pharmacist-Led Medication Reconciliation Process on Medication Discrepancies at Hospital Admission: A Pre- and Post-Intervention Analysis

Author: Mst Yeasmin Ila , Mst Surovey Sultana Mukta

Volume: Vol 8, Issue 11; November 2025

DOI: North American Academic Research, 8(11), 459-563. doi: https://doi.org/10.5281/zenodo.17795572

Abstract: Medication discrepancies at hospital admission are a common source of possible patient harm. Nurses mainly collect the first medication history but they face difficulties such as time constraints and incomplete patient knowledge while clinical pharmacists have the ability to carry out accurate reconciliations but are not always integrated into the admission process. The main objective of the study was to measure the impact of a structured, pharmacist-led medication reconciliation process, which is executed in collaboration with nursing staff, on the unintentional medication discrepancies occurring at the time of hospital admission. A quasi-experimental study was conducted for a specific period of time in a 40- bed medical-surgical unit. In the pre-intervention phase (n=100), MedRec was performed by nurses who followed the standard admission protocol. In the post-intervention phase (n=100), the nurses prepared the list of medications and included it in the clinical admission protocol which was first checked and last confirmed by the clinical pharmacist who came on duty at the hospital within the allotted time of 4 hours since admission. The primary outcome was the rate of unintentional discrepancies put down per patient. The pre-intervention group had 148 unintentional discrepancies in total (per patient mean value 1.48 ± 1.1), while the post-intervention group had 42 discrepancies (per patient mean value 0.42 ± 0.6). This indicates a 71.6% decrease in the error rate in this regard. It is a noteworthy finding that the rate of discrepancies went down significantly (p < 0.001). The major types of discrepancies were omission (52.7%) and incorrect dosage (22.3%). Pharmacist involvement was most often wanted for cardiovascular and endocrine medications. The admission MedRec protocol with a clinical pharmacist significantly reduces the rate of unintentional medication discrepancies when the pharmacist is integrated into the process and collaborates with the nursing team. Doctors' communication with patients is enhanced by the nurses' skills, while prescription accuracy is guaranteed through the pharmacists' knowledge of medications. Therefore, that is how the two professionals work together in making this process of medication safer. Keywords: Medication Reconciliation, Clinical Pharmacy, Nursing, Patient Safety, Inter-professional Collaboration, Medication Errors.

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