Evaluation of a Pharmacist-conducted Medication Reconciliation Program upon Admission in a Medical Center in Taiwan Yen-Ying Lee, M.S., PharmD 1,2, Tzu-Ying Wu, RPh 1, Mu-Lung Chen, M.S. 1, Jing-Yi Hou, RPh 1, Hsiang-Yin Chen, M.S., PharmD 1,2 1 Department of Pharmacy, Taipei Medical University-Wan Fang Hospital, Taiwan. 2 School of Pharmacy, Taipei Medical University, Taiwan Evaluation of a Pharmacist-conducted Medication Reconciliation Program upon Admission in a Medical Center in Taiwan Yen-Ying Lee, M.S., PharmD 1,2, Tzu-Ying Wu, RPh 1, Mu-Lung Chen, M.S. 1, Jing-Yi Hou, RPh 1, Hsiang-Yin Chen, M.S., PharmD 1,2 1 Department of Pharmacy, Taipei Medical University-Wan Fang Hospital, Taiwan. 2 School of Pharmacy, Taipei Medical University, Taiwan Purpose: Studies have shown that medication reconciliation can improve patient safety. However, obtaining accurate medication history on admission can be challenging in Taiwan because patients usually are not familiar with the names of their drugs. This study evaluated the performance of a medication reconciliation conducted by pharmacists with the aid of medication usage data provided by Bureau of National Health Insurance (BNHI). Methods: Patients admitted between May 2008 and September 2009 and interviewed by pharmacists using medication usage data from BNHI on admissions were included. Type and class of medication discrepancies discovered by pharmacists, medication discrepancy rate, physician acceptance rate, and time taken for intervention were studied. Furthermore, the degrees of harm that could result from these discrepancies were evaluated by four pharmacists independently. Results: Of the 3,025 patients interviewed, pharmacists were able to identify 243 patients (8%) with at least one medication discrepancy between patient medication history and admission orders. There were a total of 576 discrepancies discovered. Omission was the most common error and cardiovascular medications were the most frequently encountered drug class. About 19% of the errors prevented could have potentially caused moderate to severe harm. The average time for one intervention was 18±9.8 minutes. The physicians’ acceptance rate of pharmacist interventions was 98%. Conclusion: This medication reconciliation program has been successfully conducted by pharmacists. There were more than 500 interventions regarding medication discrepancies in a 17-month period and the acceptance rate was high. The process of reconciling is made more efficient by using medication usage data from BNHI. The objective of the study was to evaluate the performance of a medication reconciliation conducted by pharmacists with the aid of medication usage data provided by BNHI. ABSTRACTBACKGROUND PURPOSE METHOD  This retrospective study included patients admitted between May 2008 and September 2009 and interviewed by pharmacists upon admission.  The following data elements were extracted for each patient: 1.Demographics (age, gender, number of preadmission medications) 2.Types of medication discrepancies discovered by pharmacists during reconciliation 3.Classes of medications with discrepancies 4.Time spent for each intervention 5.Physicians’ acceptance rate RESULTS METHOD (Cont.)  Patients in Taiwan are covered by National health insurance. With patients’ agreements, the Bureau of National Health Insurance (BNHI) started to provide the outpatient medication lists for all patients admitted to our institution in  The pharmacy department in Wan Fang Medical Center initiated a process of medication reconciliation upon admission In May  Medication history taking could be time-consuming because most patients did not know the names of their long-term medications.  The pharmacists used the outpatient medication list from BNHI as a reference for patient interview with a hope that it could facilitate the interview process.  After patient interview, the pharmacists reconciled the medication history and admission orders, and made appropriate interventions as necessary. LIMITATIONS CONCLUSION  A retrospective, descriptive review.  No comparison group.  Among 3,026 patients interviewed, pharmacists identified 243 patients (8%) with at least one medication discrepancy at the time of hospital admission. See table 1 for baseline characteristics.  The total number of discrepancies was 576, and 112 (19%) discrepancies discovered could have caused moderate to severe harm.  The most common type of errors identified was omission, and cardiovascular medication was the top class with discrepancies.  The average time spent for one intervention was 18 ±9.8 minutes and the physicians’ acceptance rate was 98%.  More than 500 interventions regarding medication discrepancies were discovered in a 17-month period.  This program has been successfully conducted by pharmacists with high physicians’ acceptance rate.  The process of reconciling is efficient with the aid of medication usage data from BNHI.  The degrees of harm that could result from medication discrepancies were determined by four pharmacists independently.