“Medication discrepancies and errors occurring during hospital discharge represent a critical
concern, posing significant risks such as adverse patient outcomes, medication-related
readmissions, and increased health care costs. Pharmacist-led medication reconciliation
at discharge (PMRD) has emerged as a potential solution to enhance medication safety by
mitigating medication errors and reducing hospital readmissions.
Hospital discharge is a phase of care in which patients often become more vulnerable
due to the absence of monitoring and assistance with medication administration. Previous
publications from the Multi-Center Medication Reconciliation Quality Improvement Study
(MARQUIS) have revealed a reduction in potentially harmful discrepancies in admission
and discharge orders through a multifaceted medication reconciliation implementation
model.8,9 However, these studies did not further assess the unintentional discrepancies that
were identified, leaving a gap in understanding their potential for patient harm. While
Muller and colleagues have evaluated potential patient harm avoided through pharmacist
intervention in resolving discharge medication reconciliation discrepancies, there remains a
need for further investigation into the financial implications of such interventions.”