This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (46)  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Topic Collections  • Adverse Effects  • Alert me on articles by topic  Social Bookmarking   What's this?

Jeffrey L. Schnipper, MD, MPH; Jennifer L. Kirwin, PharmD, BCPS; Michael C. Cotugno, PharmD; Stephanie A. Wahlstrom, PharmD; Brandon A. Brown, PharmD; Emily Tarvin, BA; Allen Kachalia, MD, JD; Mark Horng, MD; Christopher L. Roy, MD; Sylvia C. McKean, MD; David W. Bates, MD, MSc

Arch Intern Med. 2006;166:565-571.

Background  Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs.

Methods  We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs.

Results  Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization.

Conclusions  Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.

Author Affiliations: Brigham and Women’s/Faulkner Hospitalist Program (Drs Schnipper, Kachalia, Roy, and McKean); Division of General Medicine, Brigham and Women's Hospital and Harvard Medical School (Drs Schnipper, Kachalia, Horng, Roy, McKean, and Bates and Ms Tarvin); School of Pharmacy, Northeastern University Bouvé College of Health Sciences (Dr Kirwin); Department of Pharmacy Services, Brigham and Women's Hospital (Drs Cotugno, Wahlstrom, and Brown); and Harvard School of Public Health (Dr Bates); Boston, Mass.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Role of pharmacists in the medical home
Bates
Am J Health Syst Pharm 2009;66:1116-1118.
FULL TEXT  

Effect of Medication Reconciliation With and Without Patient Counseling on the Number of Pharmaceutical Interventions Among Patients Discharged from the Hospital
Karapinar-Carkit et al.
The Annals of Pharmacotherapy 2009;43:1001-1010.
ABSTRACT | FULL TEXT  

A Comprehensive Pharmacist Intervention to Reduce Morbidity in Patients 80 Years or Older: A Randomized Controlled Trial
Gillespie et al.
Arch Intern Med 2009;169:894-900.
ABSTRACT | FULL TEXT  

Effect of a Pharmacist on Adverse Drug Events and Medication Errors in Outpatients With Cardiovascular Disease
Murray et al.
Arch Intern Med 2009;169:757-763.
ABSTRACT | FULL TEXT  

Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events: A Cluster-Randomized Trial
Schnipper et al.
Arch Intern Med 2009;169:771-780.
ABSTRACT | FULL TEXT  

A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial
Jack et al.
ANN INTERN MED 2009;150:178-187.
ABSTRACT | FULL TEXT  

Implementation of clinical pharmacy services in a dialysis unit
Erickson et al.
Am J Health Syst Pharm 2008;65:2011-2013.
FULL TEXT  

Medication Reconciliation at Hospital Discharge: Evaluating Discrepancies
Wong et al.
The Annals of Pharmacotherapy 2008;42:1373-1379.
ABSTRACT | FULL TEXT  

The Iowa Continuity of Care study: Background and methods
Carter et al.
Am J Health Syst Pharm 2008;65:1631-1642.
ABSTRACT | FULL TEXT  

Effectiveness of a medication discharge plan for transitions of care from hospital to outpatient settings
Lalonde et al.
Am J Health Syst Pharm 2008;65:1451-1457.
ABSTRACT | FULL TEXT  

Evaluation of an Inpatient Computerized Medication Reconciliation System
Turchin et al.
J. Am. Med. Inform. Assoc. 2008;15:449-452.
ABSTRACT | FULL TEXT  

Realizing the pharmacoeconomic benefit of clinical pharmacy
Kaboli
Am J Health Syst Pharm 2008;65:1123-1123.
FULL TEXT  

Update in Hospital Medicine
Amin and Pistoria
ANN INTERN MED 2007;147:628-632.
FULL TEXT  

Clinical documentation for patient care: Models, concepts, and liability considerations for pharmacists
Zierler-Brown et al.
Am J Health Syst Pharm 2007;64:1851-1858.
ABSTRACT | FULL TEXT  

Strategic approach for improving the medication-use process in health systems: The high-performance pharmacy practice framework
Vermeulen et al.
Am J Health Syst Pharm 2007;64:1699-1710.
ABSTRACT | FULL TEXT  

The Tension between Needing to Improve Care and Knowing How to Do It
Auerbach et al.
NEJM 2007;357:608-613.
FULL TEXT  

Tying Up Loose Ends: Discharging Patients With Unresolved Medical Issues
Moore et al.
Arch Intern Med 2007;167:1305-1311.
ABSTRACT | FULL TEXT  

ASHP Long-Range Vision for the Pharmacy Work Force in Hospitals and Health Systems: Ensuring the Best Use of Medicines in Hospitals and Health Systems
Am J Health Syst Pharm 2007;64:1320-1330.
FULL TEXT  

Impact of a Pharmacy Resident on Hospital Length of Stay and Drug-Related Costs
Terceros et al.
The Annals of Pharmacotherapy 2007;41:742-748.
ABSTRACT | FULL TEXT  

Improving adherence in patients with alcohol dependence: A new role for pharmacists
Peterson
Am J Health Syst Pharm 2007;64:S23-S29.
ABSTRACT | FULL TEXT  

Insufficient communication about medication use at the interface between hospital and primary care
Glintborg et al.
Qual Saf Health Care 2007;16:34-39.
ABSTRACT | FULL TEXT  

Design and Implementation of an Application and Associated Services to Support Interdisciplinary Medication Reconciliation Efforts at an Integrated Healthcare Delivery Network
Poon et al.
J. Am. Med. Inform. Assoc. 2006;13:581-592.
ABSTRACT | FULL TEXT  

Escalating polypharmacy
Gorard
QJM 2006;99:797-800.
ABSTRACT | FULL TEXT  

Proposed model for assuring quality of Medicare's medication therapy management
Chen and Thompson
Am J Health Syst Pharm 2006;63:1167-1171.
FULL TEXT  

Clinical pharmacists and inpatient medical care: a systematic review.
Kaboli et al.
Arch Intern Med 2006;166:955-964.
ABSTRACT | FULL TEXT