Received: 11 March 2021 | Revised: 7 April 2021 | Accepted: 15 April 2021

DOI: 10.1111/jcpt.13431

ORIGINAL ARTICLE

Impact of an integrated medication reconciliation model led

by a hospital clinical pharmacist on the reduction of post-­
discharge unintentional discrepancies

Ivana Marinović MPharm1 | Vesna Bačić Vrca MPharm, PhD1,2 |

Ivana Samardžić MPharm1 | Srećko Marušić MD, PhD3 | Ivica Grgurević MD, PhD4 |
Ivan Papić MPharm1 | Dijana Grgurević MPharm1 | Marko Brkić MD5 |
Nada Jambrek MPharm6 | Jasna Mesarić MD, PhD7

1
Department of Clinical Pharmacy,
University Hospital Dubrava, Zagreb, Abstract
Croatia
What is known and Objective: There is no optimal standardized model in the transfer
2
Faculty of Pharmacy and Biochemistry,
University of Zagreb, Zagreb, Croatia
of care between hospitals and primary healthcare facilities. Transfer of care is a criti-
3
Department of Endocrinology, University cal point during which unintentional discrepancies, that can jeopardize pharmacother-
Hospital Dubrava, Zagreb, Croatia apy outcomes, can occur. The objective was to determine the effect that an integrated
4
Department of Gastroenterology,
medication reconciliation model has on the reduction of the number of post-­discharge
University Hospital Dubrava, Zagreb,
Croatia unintentional discrepancies.
5
Community Health Center Zagreb-­East, Methods: A randomized controlled study was conducted on an elderly patient popu-
Zagreb, Croatia
6 lation. The intervention group of patients received a medication reconciliation model,
City Pharmacies Zagreb, Zagreb, Croatia
7
Faculty of Health Sciences, Libertas
led entirely by a hospital clinical pharmacist (medication reconciliation at admission,
International University, Zagreb, Croatia review and optimization of pharmacotherapy during hospitalization, patient educa-

Correspondence
tion and counselling, medication reconciliation at discharge, medication reconcilia-
Ivana Marinović, Department of Clinical tion as part of primary health care in collaboration with a primary care physician and
Pharmacy, University Hospital Dubrava,
Zagreb 10000, Croatia.
a community pharmacist). Unintentional discrepancies were identified by comparing
Email: imarinov@kbd.hr the medications listed on the discharge summary with the first list of medications
prescribed and issued at primary care level, immediately after discharge. The main
outcome measures were incidence, type and potential severity of post-­discharge un-
intentional discrepancies.
Results and discussion: A total of 353 patients were analysed (182 in the intervention
and 171 in the control group). The medication reconciliation model, led by a hospital
clinical pharmacist, significantly reduced the number of patients with unintentional
discrepancies by 57.1% (p < 0.001). The intervention reduced the number of patients
with unintentional discrepancies associated with a potential moderate harm by 58.6%
(p < 0.001) and those associated with a potential severe harm by 68.6% (p = 0.039).
The most common discrepancies were incorrect dosage, drug omission and drug com-
mission. Cardiovascular medications were most commonly involved in unintentional
discrepancies.

J Clin Pharm Ther. 2021;00:1–8. wileyonlinelibrary.com/journal/jcpt© 2021 John Wiley & Sons Ltd | 1
2 |
What is new and Conclusion: The integrated medication reconciliation model, led by
a hospital clinical pharmacist in collaboration with all health professionals involved
in the patient's pharmacotherapy and treatment, significantly reduced unintentional
discrepancies in the transfer of care.
KEYWORDS
clinical pharmacist, elderly patients, medication reconciliation, unintentional discrepancies
1 | W H AT I S K N OW N A N D O B J EC TI V E
Patient safety is a priority of health care. In order to improve patient
safety, preventive measures for avoidance of medication errors and
1
harmful consequences should be implemented. In 2017, the WHO
launched the ‘Medication Without Harm’ project, which aims to re-
duce the number of severe avoidable medication-­related harm by
50% over the next five years. 2 Patient transfers between different
levels of health care are critical points for the development of ad-
verse drug events (ADEs), especially during discharge.3 A third to
a half of ADEs are associated with medication errors.4 More than
a half of medication errors occurring at transfers of care can be at-
5
tributed to unintentional medication discrepancies. A review paper
by Alqenae et al.6 showed a wide range of incidence of unintentional
discrepancies after hospital discharge (14%–­93.5%). Such discrep-
ancies occur due to a lack of professional coordination of pharma-
7
cotherapy information in the health system. Considerable health
resources are spent on hospital therapy optimization, so it is crucial
to ensure the correct implementation of pharmacotherapies in the
period following patient's discharge from the hospital. Medication
reconciliation is an effective process in reducing unintentional dis-
crepancies.8–­11 In addition, medication reconciliation is a particularly
valuable process for vulnerable groups of patients, such as elderly
patients with multiple comorbidities and polytherapies.9,12,13 The
lack of caregivers and the cognitive impairment of elderly patients
often make it difficult for the patient to notice discrepancies in
pharmacotherapy.
Different medication reconciliation models have been tested
to ensure the continuity of pharmacotherapy information between
hospitals and primary healthcare facilities, but no model has been
declared as the standard and optimal approach.14 Therefore, various
calls have been made to strengthen the evidence base prior to wide-
spread adoption.11,15,16
One of the priorities of the WHO project is reducing drug-­related
harm during transfer of care.17 In order to find a comprehensive
solution to the transfer of care issue, a pilot project titled ‘The effect
of implementing an integrated model of medication reconciliation on
the frequency of unintentional discrepancies and patient safety’ was
launched at University Hospital Dubrava and Community Health
Centre Zagreb—­East. This process was entirely led by a hospital
clinical pharmacist but included collaboration with all health pro-
fessionals involved in patients’ pharmacotherapies (hospital clinical
pharmacists, hospital physicians, primary care physicians and com-
munity pharmacists), as well as the patients themselves. The aim
MARINOVIĆ MPHARM et al.
of the study was to evaluate the impact of integrated medication
reconciliation model on the incidence, type and potential severity
of unintentional discrepancies in primary health care after hospital
discharge.
2 | M E TH O D S
2.1 | Setting and participants
A prospective randomized control study was conducted from
December 2018 to March 2020 at University Hospital Dubrava,
Zagreb, Croatia, Community Health Centre Zagreb—­East and com-
munity pharmacies in the City of Zagreb and Zagreb County. Patients
aged 65 or older were eligible to participate if they had been admit-
ted to an internal medicine department, if they had received primary
health care at the Community Health Centre Zagreb—­East, and if
they had reported the use of two or more medications. University
Hospital Dubrava is a tertiary care 600-­bed teaching institution. The
Internal Medicine Department consists of eight units: Cardiology,
Gastroenterology, Endocrinology, Nephrology, Pulmonology,
Haematology, Rheumatology and Intensive Care Unit. Patients were
excluded if they were unwilling to sign the informed consent or did
not have a caregiver willing to sign the consent form on their behalf.
Patients who met the eligibility criteria were randomly assigned to
the intervention or control group, using a computer-­generated sam-
pling table of random numbers.
Design (development) of integrated medication reconciliation
and education of health professionals.
The integrated medication reconciliation model used in this
study was designed and developed in collaboration with:
• University Hospital Dubrava,
• The Agency for Quality and Accreditation in Health Care and
Social Welfare,
• The Clinical Pharmacy Section of the Croatian Pharmaceutical
Society,
• The Croatian Society for Quality Improvement of Health Care of
the Croatian Medical Association,
• The Community Health Centre Zagreb—­East and
• City Pharmacies Zagreb.
During a series of project team meetings over a period of
1 year, all issues concerning the characteristics of the model
MARINOVIĆ MPHARM et al.
were resolved. After the establishment of the model, educational
courses were held to train the medical staff involved in the re-
search in order for them to become acquainted with the research
protocol.
2.2 | Control group
Participants in the control group received standard health care pro-
vided by hospital and primary care physicians and nurses.
2.3 | Intervention group
The integrated model represents a structured process of medica-
tion reconciliation, along with other pharmaceutical interventions,
in the hospital and primary health care. The model is led by a hos-
pital clinical pharmacist. It also involves hospital physicians, primary
care physicians, community pharmacists and patients. The standard-
ized process of medication reconciliation is in accordance with the
Protocol for drug administration harmonization and the Guide for its
18
implementation.
The integrated medication reconciliation model consisted of six
parts:
1. Medication reconciliation on admission.
The hospital clinical pharmacist created the Best Possible
Medication History (BPMH) for each patient in the intervention
group within 24 h of admission.18 All discrepancies in the prescribed
therapy at admission were rectified. It also includes questionnaires
for patients on understanding their pharmacotherapy and medi-
cation adherence.19,20 Any issues related to adherence and/or un-
certainties associated with medication information were clarified
during the patient's stay.
2. Review and optimization of pharmacotherapy during the pa-
tient's hospitalization.
Pharmacotherapy was reviewed on a daily basis by the hospital
clinical pharmacist. The medication review and therapy optimiza-
tion were based on the information collected during the medica-
tion reconciliation process and contained in the hospital medical
records, clinical and laboratory data, guidelines and other relevant
information.
3. Patient education and counselling.
The hospital clinical pharmacist arranged a counselling session
and an educational meeting with the patient and/or caregiver prior to
discharge. The patients received an updated medication list that was
discussed and explained. The hospital clinical pharmacist informed
the patient and/or caregiver of any pharmacotherapy changes that
| 3
have been made during hospitalization and of the reasons for these
changes.
4. Medication reconciliation at discharge.
Prior to discharge from the hospital, the hospital clinical phar-
macist, in collaboration with the hospital physician, developed the
Best Possible Medication Discharge Plan (BPMDP).18 It served as the
benchmark list of medications that the patient should take after dis-
charge. BPMDP contained information about:
• The continuance of taking the same medications (as in the BPMH),
• The medications that the patient started taking during
hospitalization,
• The medications that had been discontinued (permanently or
temporarily) during hospitalization (as compared to the BPMH),
• The pharmacotherapy changes made during hospitalization and
• The medications whose use needed to be introduced or discontin-
ued upon discharge from hospital.
The pharmacist electronically sent the BPMDP to the primary
care physician. In addition, a simplified BPMDP was given to the pa-
tient, who was advised to bring it to every visit to their primary care
physician and community pharmacist.
5. Medication reconciliation at the Community Health Centre.
In the one-­month period after hospital discharge, in cooperation
with the primary care physician from the Community Health Centre
Zagreb—­East, unintentional discrepancies were identified by com-
paring the discharge summary medication list with the first medica-
tion list provided by the Community Health Centre after discharge.
These discrepancies were further discussed in order to determine
whether they were intentional or unintentional.
6. Medication reconciliation process involving community
pharmacists.
The pharmacotherapeutic status, determined through prior
evaluation and consultation with a primary care physician, was
further confirmed by community pharmacists. Considering the
large number of community pharmacies in the observed area, pa-
tients were advised to obtain all medications from one pharmacy
at the same time.
2.4 | Outcome measures
The main outcome measures were the differences in the incidence,
type and potential severity of post-­discharge unintentional discrep-
ancies between the intervention and control group.
Unintentional discrepancies were divided into six types: drug
omission, drug commission, substitution with a medication from the
4 | MARINOVIĆ MPHARM et al.

TA B L E 1 Patients’ baseline
Intervention group Control group
demographics and clinical characteristics
Characteristic (n = 182) (n = 171) p value

Age, years, median (IQR) 75.5 (71–­8 0) 75 (70–­8 0.5) 0.470

Gender 0.242
Female, n(%) 100 (54.9) 83 (48.5)
Body weight, kg, median (IQR) 79.5 (69–­88) 80 (70–­89) 0.475
Body height, cm, median (IQR) 168 (163–­175) 168 (163–­175) 0.734
Serum creatinine (µmol/L), 85.5 (70–­114) 89 (67.5–­131) 0.261
median (IQR)
CKD-­EPI (ml/min/1.73 m2) 63.3 (47.2 −81.3) 64.6 (42.9–­81.9) 0.702
Educational level, n (%) 0.824
No formal education 28 (15.4) 21 (12.3)
Elementary school 66 (36.3) 64 (37.4)
High school 71 (39) 68 (39.8)
College 6 (3.3) 4 (2.3)
Undergraduate 11 (6) 14 (8.2)
Residence, n (%) 0.886
Living alone 30 (16.5) 31 (18.1)
Living with family/caregiver 148 (81.3) 137 (80.1)
Nursing home 4 (2.2) 3 (1.8)
Admission to hospital, n (%) 0.501
Emergency 164 (90.1) 150 (87.7)
Elective 18 (9.9) 21 (12.3)
Recent hospitalization 56 (30.8) 55 (32.2) 0.959
History of adverse drug events 52 (28.6) 47 (27.5) 0.820
Mean number of comorbidities, 9 (6–­12) 9 (6–­12) 0.423
median (IQR)
Mean hospital length of stay, 8 (7–­11) 8 (7–­11) 0.975
median (IQR)
Mean number of prescription 9 (7–­11) 9 (7–­12) 0.328
medications (discharge),
median (IQR)

Abbreviations: AbbIQR, interquartile range; CKD-­EPI, Chronic Kidney Disease Epidemiology

Collaboration.

same pharmacotherapeutic group, incorrect dosage, dosing interval
and route of administration.
All unintentional medication discrepancies were presented to
an expert panel team consisting of hospital clinical pharmacists and
hospital clinical pharmacologist. Out of these four clinicians, two
hospital clinical pharmacists and one clinical pharmacologist were
independent researchers of the study, while the other hospital clini-
cal pharmacist was the research supervisor. Each of them had access
to the BPMH, BPMDP and the first medication list provided by the
Community Health Care Centre after discharge, as well as to all lab-
oratory test results during the patient's hospital stay and medical
documentation stored in the hospital's record data archives. They
independently classified each unintentional medication discrepancy
according to its potential to cause harm into three categories based
on the method used by Cornish et al. 21 (a) class 1—­discrepancies un-
likely to cause patient discomfort or clinical deterioration, (b) class
2—­discrepancies with the potential to cause moderate discomfort
or clinical deterioration and (c) class 3—­discrepancies with the po-
tential to result in severe discomfort or clinical deterioration. If any
disagreements between panel members occurred, additional litera-
ture was used and discussion ensued until a consensus was reached.
2.5 | Statistical analysis
Data distribution was analysed using the Shapiro-­Wilk test. For non-­
normal numerical variable distributions, the median and interquar-
tile range (IQR) were calculated, and the differences between groups
were tested using the Mann-­Whitney's test. Categorical variables
were presented as percentages and the difference between groups
was tested using the chi-­square test or Fisher's exact test. Analysis
of the comparison of the number of participants with one or more
MARINOVIĆ MPHARM et al. | 5

discrepancies was carried out using the Fisher's exact test. All test discrepancies (27% vs. 36%). The difference in impacts can partially
values were compared to a level of significance α = 0.05. p-­values be explained by the fact that their intervention only included the act
less than 0.05 were considered statistically significant. All analyses of sending the discharge letter to general practitioners or commu-
were performed using the R 4.0.3 (R Core Team, 2020). nity pharmacists by the hospital clinical pharmacist.

3 | R E S U LT S A N D D I S CU S S I O N 3.3 | Categorization of post-­discharge

3.1 | Patients’ demographic characteristics
The sample comprised 383 patients, who were randomized to the
intervention group (n = 192) and the control group (n = 191). In total,
30 participants were excluded from the analysis (10 participants in
the intervention group and 20 participants in the control group) due
to a participant request (n = 6), death before index discharge (n = 13),
transfer to another institution (n = 2) and inability to do a follow-­up
(n = 9). A total of 353 patients, 182 in the intervention group and 171
in the control group, were evaluated for analysis.
Participants’ demographic and clinical characteristics are shown
in Table 1. The two groups, control and intervention, did not differ
significantly with regard to the participants’ characteristics. In total,
1657 and 1626 medications were identified in the intervention and
the control group, respectively. According to the ATC classification,
the majority of medications were prescribed for conditions related
to the cardiovascular system (41.2% vs. 41.4%), alimentary tract
and metabolism (21.7% vs. 21.2%), blood and blood-­forming organs
(9.8% vs. 8.4%), nervous system (9% vs. 9.9%) and respiratory system
(5.3% vs. 4.9%).
3.2 | Incidence of post-­discharge unintentional
discrepancies
The number of participants with at least one discrepancy was sig-
nificantly lower in the intervention group than in the control group
(34.5% vs. 14.8%). In the intervention group, that number decreased
by 57.1% (p < 0.001). The study conducted by Hockly et al. 22
showed that the intervention reduced post-­discharge medication
unintentional discrepancies
The unintentional discrepancy types in both groups are presented
in Table 2. The number of patients with at least one discrepancy re-
lated to an incorrect dosage, drug omission and drug commission was
significantly lower in the intervention group (p = 0.003, p = 0.040,
p = 0.024). The most common type of unintentional discrepancies
was incorrect drug dose (45.3%) followed by drug omission (30.2%)
and drug commission (15.1%). Riordan et al. state in their paper that
these error types belong to the group of error types which are most
likely to persist after discharge. 23
3.4 | Potential severity of post-­discharge
unintentional discrepancies
The potential severity of unintentional discrepancies is shown in
Table 3. The intervention reduced the number of patients with un-
intentional discrepancies associated with a potential moderate harm
by 58.6% (p < 0.001) and those with a potential severe harm by
68.6% (p = 0.039). The number of observed clinically relevant un-
intentional discrepancies (class 2 and class 3) was lower in the in-
tervention group than in the control group (36 vs. 108); 90.6% of
unintentional discrepancies in the control group had the potential to
cause moderate or severe discomfort or clinical deterioration, which
is the upper limit for clinically relevant discrepancies (28%–­91%),
as Mekonnen et al.11 state in their review. The majority of patients
(84.7%) affected by unintentional discrepancies in the control group
were at risk of moderate harm (class 2). A study conducted in Ireland
also showed a high rate (86%) of patients with unintentional discrep-
ancies associated with a potential moderate harm. 23

TA B L E 2 The unintentional discrepancies in the intervention and control group

Number (%) of unintentional discrepancies Number (%) of patients with unintentional discrepancies

Intervention group Control group

Intervention group Control group (n = 182) (n = 171) p-­value

Total 39 (24.5) 120 (75.5) 27 (14.8) 59 (34.5) <0.001

Type of medication discrepancy
Incorrect dose 20 (51.3) 52 (43.3) 18 (9.9) 37 (21.6) 0.003
Drug omission 11 (28.2) 37 (30.8) 8 (4.4) 18 (10.5) 0.040
Drug commission 6 (15.4) 18 (15) 4 (2.2) 13 (7.6) 0.024
Drug substitution 1 (2.6) 6 (5) 1 (0.5) 6 (3.5) 0.060
Incorrect frequency 1 (2.6) 5 (4.2) 1 (0.5) 5 (2.9) 0.112
Incorrect route 0 (0) 2 (1.7) 0 (0) 1 (0.6) 0.484
6 | MARINOVIĆ MPHARM et al.

TA B L E 3 Potential severity of unintentional discrepancies in the intervention and control group

Number (%) of unintentional Number (%) of patients with unintentional

discrepancies discrepancies

Potential severity of unintentional Control Intervention group Control group

medication discrepancies Intervention group group (n = 182) (n = 171) p-­value

Class 1 3 (7.7) 12 (10) 3 (1.6) 10 (5.8) 0.047

Class 2 30 (76.9) 91 (75.8) 22 (12.1) 50 (29.2) <0.001
Class 3 6 (15.4) 17 (14.2) 4 (2.2) 12 (7.0) 0.039

3.5 | Medication involved in unintentional management challenging. 25,26 Hospital pharmacotherapy optimi-
discrepancies zation for hypertension requires clinical expertise and judgement,
and a large amount of financial and other resources. 27 It is therefore
According to the ATC classification, the most frequent drug class important to abide by these pharmacotherapy changes determined
involved in unintentional discrepancies was group C (cardiovascu- in the hospital, as post-­discharge unintentional discrepancies can
lar system medications). A half of all discrepancies can be attributed generate new problems associated with chronic diseases and new
to five classes of drugs: diuretics (12.6%), drugs acting on renin-­ hospitalizations. 28
angiotensin system (10.7%), antidiabetics (10.7%), drugs for acid-­ Furosemide was the most common drug associated with discrep-
related disorders (8.8%) and potassium (7.5%) (Table 4). ancies. Furosemide doses were usually not in line with the doses rec-
Previous studies have also identified cardiovascular drugs as ommended at the hospital. Certain drugs have been classified into
the most common drug class that leads to post-­discharge ADEs. different categories of potential severity, depending on the indica-
One of the most common drug subclasses reported was antihy- tion, dose and the stage of renal function impairment. For example,
pertensives.6,24 As results of this research show the majority of atorvastatin in high doses was classified into class 3 for the indica-
drugs involved in unintentional discrepancies were drugs with an- tion of secondary cardiovascular prevention, and in lower doses into
tihypertensive effect. The high prevalence of hypertension (which class 2 when the indication for its prescription was primary preven-
is 1.13 billion people worldwide according to WHO) and the fact tion. Hypoglycaemics were also found in different classes. Insulin
that guidelines often require 2 or more antihypertensive medica- has a higher risk of causing hypoglycaemia than oral hypoglycaemic
tions to achieve the targeted blood pressure make hypertension agents. Direct-­acting oral anticoagulants (DOACs) can also be found
in different classes depending on the dose and renal function. The
TA B L E 4 The most frequent ATC drug class involved in administration of DOACs requires regular monitoring of the renal
unintentional discrepancies function and the dose must be adjusted according to the stage of
renal impairment. 29 The examples of unintentional discrepancies are
The most frequent therapeutic ATC classes Number (%)
presented in Table 5.
A alimentary tract and metabolism 46 (28.9)
Drugs used in diabetes 17 (10.7)
Drugs for acid-­related disorders 14 (8.8) 3.6 | Integrated medication reconciliation model
Potassium 12 (7.5) led by a hospital clinical pharmacist
B blood and blood-­forming organs 3 (1.9)
C cardiovascular system 80 (50.3) Most research explores data on medication reconciliation conducted
Diuretics 20 (12.6) in primary or secondary health care. It is crucial for patient safety that
Agents acting on the RAS 17 (10.7) medication reconciliation includes different levels of health care and a

Beta blocking agents 10 (6.3) timely and accurate exchange of information. There are different mod-
els of medication reconciliation and ways of organizing them.8,10,14,30,31
Lipid modifying agents 10 (6.3)
Various health professionals may be involved in this process at differ-
Antihypertensives 9 (5.7)
ent levels of health care.11,14,16 It is important to emphasize that this
Calcium channel blockers 8 (5)
model was entirely led by a hospital clinical pharmacist, but included
Cardiac therapy 6 (3.8)
all health professionals associated with the patient's pharmacotherapy
J antiinfectives for systemic use 4 (2.5)
and treatment. The decision to include community pharmacists in the
N nervous system 10 (6.3) transfer of care model was important as they serve as the last pro-
R respiratory system 9 (5.7) fessional control before the drug reaches the patient. In this study,
Other 7 (4.4) patients were advised to have their medications dispensed at one com-
Abbreviations: ATC, Anatomical Therapeutic Chemical drug munity pharmacy, which should be an established medicine dispens-
classification system; RAS, Renin-­angiotensin system. ing practice. According to the London Department of Health, 60% of
MARINOVIĆ MPHARM et al. | 7

TA B L E 5 Examples of unintentional medication discrepancies

Unintentional medication discrepancy

Potential
Type severity Description

Drug dose Minor Furosemide 40 mg once daily was prescribed in primary care instead of furosemide 40 mg half a tablet
twice daily
Drug omission Moderate Trimetazidine 35 mg twice daily was introduced into patients’ pharmacotherapy during hospital stay
(angina pectoris). The drug was discontinued in primary care.
Drug addition Moderate Atorvastatin 40 mg was continued in primary care, although the drug was discontinued at the hospital
(liver lesion)
Drug dose Moderate Dose of furosemide 500 mg once daily, instead of furosemide 125 mg, twice a day
Drug substitution Moderate Perindopril/amlodipine 5/5 mg substituted with valsartan/hydrochlorothiazide 80/12.5 mg in primary care.
Drug dose Severe Primary care practitioner prescribed atorvastatin 20 mg, while in discharge letter it was stated atorvastatin
80 mg. Patient was hospitalized for chest pain. Diagnosis: unstable angina, dyslipidemia, elevated
cardiac troponin)
Drug omission Severe Upon admission to the hospital, low serum potassium levels were found, which is why potassium was
introduced into the patient's pharmacotherapy. The drug was omitted in primary health care.
Drug commission Severe Continued to use moxonidine 0.4 mg in the evening, although the discharge letter stated that moxonidine
should be discontinued due to severe renal impairment.

patients visit the same pharmacy regularly,32 and the patients visit a
community pharmacist more often than a primary care physician (13
33
vs. 7 in the period of one year). Thus, efforts should be made to in-
crease this percentage in order to maximize patient safety.
One of the priorities of the new WHO project includes active
involvement of the patient in the healthcare process. 2 Within the
scope of this study, patients were educated about all pharmacother-
apy changes and received simplified BPMDPs. Research has shown
that, by actively involving the patient in the transfer of care, better
treatment outcomes can be achieved.34,35
3.7 | Limitations
This study has several limitations. The participants were all patients
from the Internal Medicine Department. Further research is planned
to include patients from other wards in the analysis. When catego-
rizing unintentional discrepancies according to their potential to
cause harm, it is possible to divide class 3 into two subcategories:
those that will likely cause severe consequences and those that will
surely result in severe consequences. This model contributed to a
significant reduction in post-­discharge unintentional discrepancies.
However, the aim should be to eliminate all unintentional discrepan-
cies. It would be beneficial to develop an IT platform which could
promptly and efficiently identify unintentional discrepancies in the
transfer of care. In order to further improve and optimize the trans-
fer of care model, this research should be conducted periodically.
care requires standardized models that would ensure continuity of
correct and complete pharmacotherapy. The model used in this re-
search was significantly efficient in the reduction of unintentional
medication discrepancies. The model was carefully planned and led
by a hospital clinical pharmacist. As part of this comprehensive in-
tegrated medication reconciliation model, all health professionals
involved in the patient's pharmacotherapy and treatment were in-
cluded in the process, as well as the patients themselves. Due to
their specific position and pharmacotherapy knowledge, the hospital
clinical pharmacists should coordinate the transfer of care between
the hospital and the primary care to ensure correct, complete and
safe pharmacotherapy.
AC K N OW L E D G E M E N T S
The authors would like to thank to all community pharmacists and
primary care physicians who participated in conducting this re-
search. A special thanks goes to the patients and their caregivers for
the participation in this study.
PAT I E N T C O N S E N T S TAT E M E N T
All patients were informed about the study and gave their informed
consent.
C O N FL I C T O F I N T E R E S T
The authors declare that they have no conflict of interest.
ORCID
Ivana Marinović https://orcid.org/0000-0002-1612-9859

4 | W H AT I S N E W A N D CO N C LU S I O N
Unintentional discrepancies during the transfer of care can sig-
nificantly jeopardize patient safety. It is very important to raise
awareness of this problem at all levels of health care. Transfer of
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How to cite this article: Marinović I, Bačić Vrca V, Samardžić
I, et al. Impact of an integrated medication reconciliation
model led by a hospital clinical pharmacist on the reduction
of post-­discharge unintentional discrepancies. J Clin Pharm
Ther. 2021;00:1–8. https://doi.org/10.1111/jcpt.13431