PICOTIn hospitalized medsurg patients , does med reconciliatio.docx

PICOT:
In hospitalized med/surg patients , does med reconciliation
compliance compared to non-compliant medication
reconciliation impact 30 day readmission rates?
During Unit 5, you will be working on the following unit
outcomes:
· Identify levels of measurement in data collection instruments
(CO 2)
· Discuss the implications of levels of measurement for
statistical analysis (CO 2)
· Appraise the validity and reliability of data collection methods
(CO 4)
· Examine data collection methods in published research studies
(C
Here is some more information on variables...
The dependent variable is the variable a researcher is interested
in. The changes to the dependent variable are what the
researcher is trying to measure with all their fancy techniques.
The variable that depends on other factors that are measured.
An independent variable is a variable believed to affect the
dependent variable. This is the variable that you, the researcher,
will manipulate to see if it makes the dependent variable
change. The variable that is stable and unaffected by other
variables you are trying to measure. It is the presumed cause.
According to Tappen (2016), the independent variables are
defined as the variables that the researcher will manipulate to
see if a change occurs in the dependent variables. The
independent variable is the presumed cause of change. The
dependent variables are what the researcher is attempting to
measure.
WEEK 4
Ethical concerns in nursing research often do not have straight
forward solutions. Nursing research relies on collaboration and
partnerships based on mutual trust. When that trust is breached

the damage is irreversible. Honesty, openness, respect and
sensitivity to others provide the cornerstones for ethical
research. It is important that all nursing research is undertaken
from a clear ethical stance, with ethical concerns identified at
the outset and reevaluated on an ongoing basis throughout the
project.
Take a look at this video about ethical issues and human
subjects (9:38)
https://www.youtube.com/watch?v=-O5gsF5oyls (Links to an
external site.)
As nurses, our primary observations are of persons thus we need
to think about how to ethically collect data from persons.
The National Research Act of 1974 established three ethical
principles for research:
· Respect for persons
· Beneficence
· Justice
· Check out this video on Types of Sampling Methods ---
· https://www.youtube.com/watch?v=pTuj57uXWlk
Carmen,
· Probability sampling is the gold standard for ensuring
generalizability, as it uses some form of random selection in
choosing the sample units. The reason that this sample is called
a probability sample is each sampling unit has a known chance
(probability) that it will be selected (Houser, 2018).
Nonprobability sampling does not use random selection so there
is no known chance of being selected (Houser,
2018). Nonprobability samples are selected by nonrandom
methods. They are often called convenience samples, as the
selection is generally based on the convenience of obtaining
access to the population. Results from a study where the sample
was randomly selected from an accessible population can
usually be generalized to the target population far easier than
when using a convenience sample.
· Many researchers only have access to a convenience sample so
lots of studies report this type of sampling.

1Kreckman J, et al. BMJ Open Quality 2018;7:e000281.
doi:10.1136/bmjoq-2017-000281
Open Access
Improving medication reconciliation at
hospital admission, discharge and
ambulatory care through a transition of
care team
John Kreckman,1 Waiz Wasey,1 Sharron Wise,1 Tammy
Stevens,1 Lance Millburg,2
Cassie Jaeger2
To cite: Kreckman J, Wasey W,
Wise S, et al. Improving
medication reconciliation
at hospital admission,
discharge and ambulatory
care through a transition of
care team.BMJ Open Quality
2018;7:e000281. doi:10.1136/
bmjoq-2017-000281
Received 6 December 2017
Revised 5 February 2018
Accepted 7 April 2018
1Department of Family and
Community Medicine, Southern
Illinois University School of
Medicine, Springfield, Illinois,

USA
2Memorial Health System,
Springfield, Illinois, USA
Correspondence to
Dr John Kreckman;
[email protected] siumed. edu
BMJ Quality Improvement Report
AbstrAct
Medication reconciliation is an important component to
the care of hospitalised patients and their safe transition to
the ambulatory setting. In our Family Medicine Hospitalist
Service, patient care is frequently transferred between
the various physicians, residents, nurses and eventually
to a separate group of providers who provide ambulatory
management. Due to frequent transitions of care, there
was no clear ownership of the medication reconciliation
process. To improve the medication reconciliation process,
a Transition of Care Team composed of registered
nurses was created to oversee the entire reconciliation
process. The team engaged the patient and their family,
when needed, contacted patients’ pharmacies and their
providers, reconciled the patients’ hospital medication list
with the ambulatory list at hospital admission and within
24 hours of discharge, and attended the hospital follow-
up visit to verify medications and provide continuity of
care. Implementation of the team allowed for additional
investigative resources, redundancy in preventing errors
and early recovery should an error occur. The percent
of medications with error after implementation of the
Transition of Care Team was reduced from 131/386
(33.9%) to 147/787 (18.7%) at hospital admission,
81/354 (22.9%) to 42/834 (5.0%) at discharge and
43/337 (12.8%) to 6/809 (0.7%) at follow-up visit (two

proportion tests, p<0.001). In addition, the percent of
charts without any errors improved at hospital discharge
from 8/31 (25.8%) to 46/70 (65.7%) and at hospital
follow-up visit from 16/31 (51.6%) to 64/70 (91.4%)
(two-proportion test, p<0.001). Previously viewed as three
separate reconciliations occurring at admission, discharge
and hospital follow-up, the approach to medication
reconciliation was reframed as a continuous process
occurring throughout the hospitalisation and hospital
follow-up resulting in improved reconciliation accuracy
and safer transitions to the ambulatory setting.
Problem
The Family Medicine Hospitalist Service
(FMHS) at our 500-bed tertiary-care facility in
Illinois, USA, provides a broad range of inpa-
tient services. Based on case mix index and
average severity level, the FMHS patient popu-
lation is representative of the institutional
patient population. The hospital service is
composed of one attending physician and
five residents who divide the day, night and
weekend responsibilities on a rotational
basis. Patient care is frequently transferred
between the various team members and
eventually to a separate group of providers
who provide ambulatory management. The
hospital electronic medical record does not
interface with the ambulatory record of the
residency programme. Information between
the two records is transmitted in portable
document format. Consequently, manually
updating medication records at the end of
the hospital stay is a time-consuming process
and is subject to human error. An initial audit

of 30 ambulatory records of recently hospital-
ised patients in May 2016 revealed that 20/30
(66.0%) records had medication errors at the
hospital follow-up visit.
background
In 2016, medical errors were estimated to
result in 250 000 deaths annually, making
medical errors the third leading cause of
death in the USA.1 Drug-related errors are
the most common type of medical error
and can result from discrepancies in patient
medications during periods of transition of
care.2 3 Around 60% of medication errors
occur during patient admission, discharge or
transfer of care.4 It is estimated that at least
one medication error occurs each day for an
average hospitalised patient.5 Belda-Rustarazo
et al reported that 64.5% of patients had at
least one medication reconciliation error at
hospital admission.6 The percent of patients
with one or more medication discrepancy
at hospital discharge has been reported at
14.1% and 32.4%.6 7 Of the errors discovered
at hospital discharge in a prospective observa-
tional study, 51% had the potential to result
in moderate to severe harm.6
o
n
F
e
b
ru

a
ry 4
, 2
0
2
0
b
y g
u
e
st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://b
m

jo
p
e
n
q
u
a
lity.b
m
j.co
m
/
B
M
J O
p
e
n
Q
u
a
l: first p
u
b
lish
e

d
a
s 1
0
.1
1
3
6
/b
m
jo
q
-2
0
1
7
-0
0
0
2
8
1
o
n
2

0
A
p
ril 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m
http://bmjopen.bmj.com/
http://crossmark.crossref.org/dialog/?doi=10.1136/bmjoq-2017-
000281&domain=pdf&date_stamp=2018-04-20
http://bmjopenquality.bmj.com/
2 Kreckman J, et al. BMJ Open Quality 2018;7:e000281.
doi:10.1136/bmjoq-2017-000281

Open Access
In a prospective study of 400 discharged patients, 66%
of adverse events that occurred were adverse drug events
and one-third of all adverse events were considered
preventable.8 Medication reconciliation, a comparison of
a patient’s medication list with the physician’s for accu-
racy of drug type, dose, frequency and route of medica-
tion at hospital admission, transfer and discharge, can
reduce medication errors.9 However, a challenge often
faced by institutions is that there is no clear owner of the
medication reconciliation process.9 In 2011, The Joint
Commission incorporated medication reconciliation
into a National Patient Safety goal and required organisa-
tions to ‘maintain and communicate accurate medication
information’ and ‘compare the medication information
the patient brought into the hospital with the medica-
tions ordered for the patient by the hospital in order to
identify and resolve discrepancies’.10 In a previous study,
implementing medication review by a pharmacist at
hospital admission and creating a discharge medication
reconciliation form and report that patients can take
home with them reduced medication errors from 57%
to 33%.11
baseline measuremenT
The accuracy of medication reconciliation was measured
at admission, discharge and hospital follow-up. A medi-
cation error was defined as any incorrect labelling, inclu-
sion or exclusion of a medication that the practitioner
believed was likely to result in incorrect usage. A medi-
cation was included if it was provider rather than patient
directed. For example, omeprazole or aspirin, both avail-
able over the counter, were included, but only if directed
by the provider. Each medication error was counted once
even if it had more than one error. If omeprazole was

written as 20 mg daily but should have been written as
40 mg twice daily, it would only be counted as one error
even though both the dose and the frequency were incor-
rect. Percentages were calculated using the number of
discrete errors in the numerator and the total number
of discrete medications in the final reconciled list as the
denominator with an error rate limited to 100%. The
same definition of a medication error was used for the
initial audit, preintervention chart review and postinter-
vention chart review.
Before initiation of the project, the admission recon-
ciliation consisted of a two-step verification process
performed by hospital nursing staff trained to perform
the task. Following medication verification from at least
two sources, typically with the patient’s primary care
office, preferred pharmacy and/or previous discharge
summary or history from the physician, the nursing staff
populated the medication list into the hospital electronic
record and forwarded it to the FMHS resident for verifica-
tion and signature. Due to the time required for comple-
tion of the two-step verification, frequently the verifying
resident was not the same resident who actually admitted
the patient.
During the hospital course, medications are added,
removed and adjusted by various FMHS team members
as well as other services involved in the patient’s care. At
the time of discharge, the final medication lists are recon-
ciled back into the ambulatory record by the discharging
resident and then forwarded to the patient’s primary care
provider for verification.
At the hospital follow-up visit, the previously reconciled
ambulatory record is reviewed by nursing staff and verified
by the treating resident. In almost all cases, the admitting,

verifying, discharging and hospital follow-up visit resi-
dents are different individuals each having varying levels
of involvement in the patient's care (figure 1). Staff spend
approximately 30 min at hospital admission and 10 min at
hospital discharge and follow-up completing the medica-
tion reconciliation process.
A second chart review of 31 records of recently hospi-
talised patients completed 2 months prior to the interven-
tion, defined as preintervention, revealed that 131/386
(33.9%) of medications contained errors at hospital
admission, 81/354 (22.9%) of medications contained
errors at discharge and 43/337 (12.8%) of medications
contained errors at the hospital follow-up visit. Only
7/31 (22.6%) charts at admission, 8/31 (25.8%) charts
at discharge and 16/31 (51.6%) charts at the hospital
follow-up visit did not contain any errors.
design
In June 2016, FMHS staff were educated on medication
reconciliation, FMHS’s current medication error rate, and
began participating in chart reviews for preintervention
data collection. Using the Lean Six Sigma model of Define,
Measure, Analyse, Improve and Control, the medication
reconciliation inaccuracy was evaluated. Process mapping
and a failure modes effect analysis was used to analyse
the FMHS medication reconciliation process. Lean Six
Sigma methodology determined that the primary cause
of inaccurate medication reconciliation was its silo struc-
ture. Admission, discharge and hospital follow-up, along
with their coinciding medication reconciliations, were
treated as separate processes. As three separate processes
performed by different individuals, medication reconcil-
iation lacked ownership making feedback and accounta-
bility difficult. To remove the silo structure, a Transition
of Care Team, with ownership of the entire reconciliation

process, was created. The Transition of Care Team was
implemented in November 2016. A preintervention–
postintervention design was chosen in order to include
all patients in the intervention, meet Joint Commission’s
National Patient Safety goal for medication reconciliation
and to help reduce medication error risk.
The percent of charts and medications with errors
was measured by a convenience sample in June, July
and August 2016 preintervention and November 2016,
December 2016 and January, March, June and September
2017 after the intervention. Patient age, gender, severity
of illness, length of stay, complications of care, 30-day
o
n
F
e
b
ru
a
ry 4
, 2
0
2
0
b
y g
u
e

st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://b
m
jo
p
e
n
q
u
a
lity.b
m
j.co
m
/

B
M
J O
p
e
n
Q
u
a
l: first p
u
b
lish
e
d
a
s 1
0
.1
1
3
6
/b
m

jo
q
-2
0
1
7
-0
0
0
2
8
1
o
n
2
0
A
p
ril 2
0
1
8
. D
o
w

n
lo
a
d
e
d
fro
m
doi:10.1136/bmjoq-2017-000281
Open Access
readmission and mortality rate were measured for the
Family Medicine Hospitalist service from the Crimson
database 12 months before and after the initial educa-
tional intervention in June 2016. Complications of care
are based on International Classification of Diseases
codes for complications of a device, implant or graft,
surgical procedure or from medical care that occurred
during the hospital stay. Two-proportion tests were used
to determine differences in the percent of medications
with errors, the percent of charts without errors, gender,
severity of illness, complications of care, 30-day readmis-
sion and mortality rate before and after the intervention.
Chi-square analysis was used to determine differences
in severity of illness, determined by All Patient Refined
Diagnosis Related Groups. Mann-Whitney U tests were

performed to determine differences in patient age
and length of stay. A P value of <0.05 was considered
significant.
sTraTegy
Plan-do-study-act 1—education—June 2016
FMHS staff were educated on the patient benefits of accu-
rate medication reconciliation. The current FMHS medi-
cation reconciliation performance was shared, including
the percentage of charts in the initial audit in May 2016
that contained medication errors. Staff were encour-
aged to maintain accurate medication reconciliation and
participate in the Lean Six Sigma project.
Plan-do-study-act 2—Transition of care Team
implemented—november 2016
Faced with an at-risk population with low health literacy
and a hospital team composed of frequently rotating
residents, a transitional support structure of registered
nurses was created called the Transition of Care Team.
Depending on multiple factors including the complexity
of the medical history, the accuracy of their personal
records, the extent of family support, the number of
prescribers and pharmacies, as well as the number of
recent medication changes, reconciliation can be a very
time-consuming process. Unencumbered by the silo
structure of the hospital management, the Transition of
Care Team was free to move the ambulatory record medi-
cation reconciliation from the time of discharge to the
time of admission. This provided the team ample time to
investigate the patient's medications.
Beginning with the patient’s ambulatory medication
list and comparing this with the list comprised by the
hospital team, the patient and their family were then
engaged, by the Transition of Care Team, to address

any discrepancies. The majority of the medications are
reconciled at this point. However, further investigation
is occasionally needed to clarify persisting discrepancies.
This deeper investigation requires a significant amount
of time and includes the review of the patient’s medical
record, contacting the patients’ pharmacies and their
providers, bringing medications from home and in some
cases home visits. The investigative process continues,
Figure 1 Medication reconciliation process at hospital
admission, discharge and follow-up visit. At hospital admission,
nursing staff complete a two-step verification of medications,
update the electronic record and notify the resident to sign off
on the list. At discharge, medications are reconciled in the
hospital and ambulatory records are forwarded to the patient’s
provider. At hospital follow-up visit, both nursing staff and
residents verify the medication list. Frequently, the admitting,
verifying, discharging and hospital follow-up residents are
different individuals. The Transition of Care Team begins
ambulatory
medication reconciliation at admission, reviews the list again
within 24 hours of discharge and attends the follow-up visit to
provide continuity of care. Use of the Transition of Care Team
removed the silo structure of the initial medication
reconciliation
process. FMHS, Family Medicine Hospitalist Service.
o
n
F
e
b
ru
a

ry 4
, 2
0
2
0
b
y g
u
e
st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://b
m
jo

p
e
n
q
u
a
lity.b
m
j.co
m
/
B
M
J O
p
e
n
Q
u
a
l: first p
u
b
lish
e
d

a
s 1
0
.1
1
3
6
/b
m
jo
q
-2
0
1
7
-0
0
0
2
8
1
o
n
2

0
A
p
ril 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m
doi:10.1136/bmjoq-2017-000281
Open Access
gathering additional information and gradually refining
the medication list until the professional satisfaction of

the Transition of Care Team and the providers is met.
When the Transition of Care Team determined that no
further medication changes were implemented after
reviewing the various prescribing sources, the reconcili-
ation was determined complete. The reconciled ambula-
tory medication list is generally completed within a few
days of hospital admission and is then used to provide
feedback to the hospital and the FMHS teams. Medica-
tions are reviewed weekly by a Doctor of Pharmacy on the
FMHS team.
Having established a reliable ambulatory medication
record at the time of discharge, the discharging resident
only needs to update the ambulatory list with the changes
made during the inpatient stay. Within 24 hours of
discharge, the Transition of Care Team reviews the recon-
ciled ambulatory record against the patient’s discharge
record, providing a second opportunity for feedback and
correction to the FMHS team.
At the hospital follow-up visit within 30 days after
discharge, the resident reconciles the ambulatory record
again updating any changes that occurred since discharge.
Present at the hospital follow-up visit, the Transition of
Care Team reviews the reconciled record for accuracy
providing a third opportunity for feedback and correction.
Having established a relationship with the patient at the
time of admission, and participating in the management
decisions during the patient’s hospitalisation, the Tran-
sition of Care Team's presence at the hospital follow-up
visit provides insight into the discharge management plan
and continuity for both the resident and patient who may
be meeting for the first time (figure 1).
We hypothesised that reframing reconciliation as a
single continuous process beginning at hospital admission

and continuing through discharge and hospital follow-up
would improve the admission medication reconcilia-
tion, which would improve the discharge reconciliation,
impacting the initial goal of improved medication recon-
ciliation at hospital follow-up.
resulTs
Following addition of the Transition of Care Team and
redesign of the medication reconciliation process, the
accuracy of reconciliation at admission, discharge and
hospital follow-up was measured for 70 patients postint-
ervention.
The percent medications with errors was reduced at
all three junctures of reconciliation. At admission, the
percent of medications with errors was reduced from
131/386 (33.9%) to 147/787 (18.7%) (two-proportion
test, p<0.001). At hospital discharge, the percent of medi-
cations with errors was reduced from 81/354 (22.9%) to
42/834 (5.0%) (two-proportion test, p<0.001). Percent
medications with errors at hospital follow-up visit was
reduced from 43/337 (12.8%) to 6/809 (0.7%) (two-pro-
portion test, p<0.001) (figure 2). The percent of charts
without any errors improved at hospital discharge from
8/31 (25.8%) to 46/70 (65.7%) (two-proportion test,
p<0.001) and at hospital follow-up visit from 16/31
(51.6%) to 64/70 (91.4%) (two-proportion test, p<0.001)
(figure 3). Severity of illness was statistically different
between the pre and post groups (χ2, p=0.002), with
the postintervention group containing an increased
percentage of patients with a severity score of 1 and a
decreased percentage of patients with a severity score of
3 (two-proportion test, p<0.001, p=0.037, respectively).
The percent of patients with complications of care was
significantly reduced from 18/1198 (1.5%) before

the intervention to 6/1135 (0.5%) after the interven-
tion (two proportion test, p=0.018). A decreased trend
in 30-day readmissions was observed postintervention
(two-proportion test, p=0.054). A larger sample size may
be needed to detect a statistically significant reduction in
Figure 3 Percent of charts without any errors was increased
at hospital discharge and follow-up visit after implementation
of the Transition of Care Team. Percent charts without errors
was measured by a convenience sample of 31 patients
before the intervention and 70 patients after the intervention.
Two-proportion test, *P<0.001.
Figure 2 Percentage of medications with errors was
reduced at hospital admission, discharge and follow-up visit
after implementation of the Transition of Care Team. Percent
medications with errors was measured by a convenience
sample of 31 patients before the intervention and 70 patients
after the intervention. Medication errors were counted only
once even if the medication had more than one type of error.
Two-proportion test, *P<0.001.
o
n
F
e
b
ru
a
ry 4
, 2
0

2
0
b
y g
u
e
st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://b
m
jo
p
e
n
q
u

a
lity.b
m
j.co
m
/
B
M
J O
p
e
n
Q
u
a
l: first p
u
b
lish
e
d
a
s 1
0

.1
1
3
6
/b
m
jo
q
-2
0
1
7
-0
0
0
2
8
1
o
n
2
0
A
p
ril 2

0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m
doi:10.1136/bmjoq-2017-000281
Open Access
30-day readmission rates. We continue to monitor 30-day
readmission rates for FMHS. There were no significant
differences in patient age, gender or mortality rate prein-
tervention and postintervention (table 1).
To sustain the process improvements and prevent
drift back to baseline, the FMHS implemented a control

plan that measures medication reconciliation accuracy
quarterly. Beginning with a single registered nurse, the
Transition of Care Team has grown to include three full-
time employees as the team’s value and responsibilities
have increased to include paediatrics and newborns.
Implementation of the Transition of Care Team has led
to 6 months of sustained improvement in reconciliation
accuracy.
lessons and limitations
Viewed as a value chain, hospital management is the sum
of each of its core processes. The admission, discharge
and transition to the ambulatory care environment is a
service stream composed of many nested core processes
each adding either value or waste to the patient’s care.
A key component of process improvement that is often
overlooked is the necessity of building support structures
that enhance the efficiency of the core processes.
This study is unique in that the Transition of Care Team
was composed of registered nurses. Most institutions rely
on pharmacists to perform medication reconciliation,
consuming a significant amount of their time and taking
them away from other responsibilities.3 However, the
success of our intervention was as effective as pharmacy-led
interventions in the literature. For example, Murphy et al,
implemented a team of pharmacists to complete medi-
cation reconciliation within 24 hours of admission and
reduced the percent of medication errors at discharge
from 57% to 33%, compared with 22.9% to 5.0% in our
study (figure 2).11 Scarsi et al increased the number of
patients without a medication error during hospitalisa-
tion from 22.9% to 40% by including pharmacists in daily
medical rounds, compared with 25.8% to 65.7% in our
study (figure 3).12

According to Karnon et al, interventions that improve
medication reconciliation are cost-effective for prevent-
able adverse drug events compared with no intervention.
However, their review found that nurses took a longer
duration of time to complete medication reconciliation
when using a standardised patient history form compared
with pharmacy driven reconciliation, increasing the
costs of nursing interventions.13 Although additional
information is needed to make a direct comparison, the
nursing-based intervention at our institution allowed
pharmacists to focus on other responsibilities and was
considered a cost-effective investment to provide great
patient care.
The Transition of Care Team support structure provides
two opportunities. First, the addition of the Transition
of Care Team allowed the FMHS to reframe medication
reconciliation into a single continuous process beginning
at admission and continuing through the follow-up visit.
In this way, each subsequent reconciliation builds on
Table 1 Complications of care were significantly reduced after
implementation of the Transition of Care Team
Preintervention Postintervention P values
Age (median) 54 54 Mann-Whitney U test, p=0.133
Gender—female 700/1198 (58.4%) 696/1135 (61.3%) Two-
proportion test, p=0.154
Gender—male 498/1198 (41.6%) 439/1135 (38.7%) Two-
Severity 1—minor 151/1198 (12.6%) 207/1135 (18.2%) χ2,

p=0.002,
two-proportion test, p<0.001
Severity 2—moderate 451/1198 (37.6%) 409/1135 (36.0%)
Two-proportion test, p=0.420
Severity 3—major 496/1198 (41.4%) 422/1135 (37.2%) Two-
Severity 4—extreme 100/1198 (8.3%) 96/1135 (8.5%) Two-
No severity score listed 0/1198 (0%) 1/1135 (0.1%) Two-
Length of stay (median) 3 Days
(4.4 days average)
3 Days
(4.0 days average)
Mann-Whitney U test, p=0.003
Complications of care 18/1198 (1.5%) 6/1135 (0.5%) Two-
30-Day readmission with
exclusions (any APR-DRG)*
180/1107 (16.3%) 141/1058 (13.3%) Two-proportion test,
p=0.054
Mortality rate with exclusions* 22/1197 (1.8%) 19/1132 (1.7%)
Two-proportion test, p=0.770
Patient characteristics were measured for the Family Medicine

Hospitalist service from the Crimson database 12 months before
and after the
intervention.
*Crimson 30-day readmission excluded Centers for Medicare
and Medicaid Services (CMS) approved readmissions including
chemotherapy,
radiotherapy, dialysis, rehabilitation, elective admission,
patients discharged against medical advice, mortalities, length
of stay greater than
1 year and transfers to other acute-care facilities. All severity
adjusted All Patient Refined Diagnosis Related Groups (APR-
DRGs) were
included in the readmission data. Mortality rate excluded cases
with uncertainty of how much influence the physician had on
the case
including chemotherapy and radiotherapy patients, length of
stay over 1 year, inpatient transfers from other acute-care
facilities and hospice
patients according to Crimson guidelines.
o
n
F
e
b
ru
a
ry 4
, 2
0
2
0

b
y g
u
e
st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://b
m
jo
p
e
n
q
u
a
lity.b

m
j.co
m
/
B
M
J O
p
e
n
Q
u
a
l: first p
u
b
lish
e
d
a
s 1
0
.1
1

3
6
/b
m
jo
q
-2
0
1
7
-0
0
0
2
8
1
o
n
2
0
A
p
ril 2
0

1
8
. D
o
w
n
lo
a
d
e
d
fro
m
doi:10.1136/bmjoq-2017-000281
Open Access
the accuracy of the previous one. Second, by providing
additional investigative resources at admission as well as
a mechanism for immediate feedback and accountability
to the FMHS team, the team provides redundancy to
prevent errors and a recovery mechanism to detect and
correct errors before causing patient harm.
Complications of care were significantly reduced
postintervention. Although encouraging, we cannot

claim differences are direct outcomes of the intervention
due to the complexity of patient outcomes and poten-
tial confounders including differences in severity of
illness (table 1). A limitation of the study was that it was
performed at a single institution and results cannot be
generalised.
Finally, applying lessons learnt from the Transition of
Care Team’s management of medication reconciliation,
the FMHS is currently looking into other opportunities
to leverage the team’s support to other core process
including assessment for social determinants of health,
scheduling ambulatory appointments, transitional phone
support and implementation of the discharge plan.
conclusion
Team-based care using multiple providers often results
in no clear ownership of the medication reconciliation
process. Creating of a Transition of Care Team of regis-
tered nurses restructured medication reconciliation as a
continuous process occurring throughout patient hospi-
talisation, discharge and hospital follow-up and improved
medication reconciliation accuracy, care of hospitalised
patients, and led to safer transitions to the ambulatory
setting.
Contributors JK contributed to the study concept and design,
acquisition of data,
analysis of data, critical review of the manuscript and study
supervision. JK is
responsible for the overall content as guarantor. WW
contributed to the drafting and
critical revision of the manuscript. LM contributed to
acquisition and analysis of the
data. TS and SW contributed to acquisition of the data and
administrative support.

CJ contributed to data analysis, drafting of the manuscript and
critical revision to
the manuscript. All contributors reviewed the manuscript.
Funding The transition of care team is funded by the
Department of Health and
Human Services Section 330: Grant # H80CS25098.
Competing interests None declared.
Patient consent Not required.
Ethics approval This project was reviewed by the local
institutional review board. It
was determined that this project was not research involving
human subjects.
Provenance and peer review Not commissioned; externally peer
reviewed.
Open Access This is an Open Access article distributed in
accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC
4.0) license, which
permits others to distribute, remix, adapt, build upon this work
non-commercially,
and license their derivative works on different terms, provided
the original work is
properly cited and the use is non-commercial. See: http://
creativecommons. org/
licenses/ by- nc/ 4. 0/
© Published by the BMJ Publishing Group Limited. For
permission to use (where
not already granted under a licence) please go to http://www.
bmj. com/ company/

products- services/ rights- and- licensing/
references
1. Makary MA, Daniel M. Medical error—the third leading
cause of
death in the US. BMJ 2016;353:i2139.
2. Roehr B. Institute of medicine report strives to reduce
medication
errors. BMJ 2006;333:220.
3. Kwan JL, Lo L, Sampson M, et al. Medication reconciliation
during
transitions of care as a patient safety strategy: a systematic
review.
Ann Intern Med 2013;158:397–403.
4. Rozich J, Resar R. Medication safety: one organization’s
approach to
the challenge. JCOM 2001;8:27–34.
5. Aspden P, Wolcott J. Committee on Identifying and
Preventing
Medication Errors. Preventing medication errors: quality chasm
series: The National Academies Press, 2007.
6. Belda-Rustarazo S, Cantero-Hinojosa J, Salmeron-García A,
et al.
Medication reconciliation at admission and discharge:
an analysis
of prevalence and associated risk factors. Int J Clin Pract
2015;69:1268–74.
7. Coleman EA, Smith JD, Raha D, et al. Posthospital
medication

discrepancies: prevalence and contributing factors. Arch Intern
Med
2005;165:1842–7.
8. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and
severity of
adverse events affecting patients after discharge from the
hospital.
Ann Intern Med 2003;138:161–7.
9. How-to guide: prevent adverse drug events by implementing
medication reconciliation. Cambridge, MA: Institute for
Healthcare
Improvement, 2001.
10. Agency for Healthcare Research and Quality. Medication
reconciliation. Patient safety primer. https:// psnet. ahrq. gov/
primers/
primer/ 1/ medication-
reconciliation?q=medication+reconciliation
(accessed 13 Nov 2017).
11. Murphy EM, Oxencis CJ, Klauck JA, et al. Medication
reconciliation
at an academic medical center: implementation of a
comprehensive
program from admission to discharge. Am J Health Syst Pharm
2009;66:2126–31.
12. Scarsi KK, Fotis MA, Noskin GA. Pharmacist participation
in
medical rounds reduces medication errors. Am J Health Syst
Pharm
2002;59:267–70.
13. Karnon J, Campbell F, Czoski-Murray C. Model-based

cost-
effectiveness analysis of interventions aimed at preventing
medication error at hospital admission (medicines
reconciliation).
J Eval Clin Pract 2009;15:299–306.
o
n
F
e
b
ru
a
ry 4
, 2
0
2
0
b
y g
u
e
st. P
ro
te
cte
d
b

y co
p
yrig
h
t.
h
ttp
://b
m
jo
p
e
n
q
u
a
lity.b
m
j.co
m
/
B
M
J O
p
e

n
Q
u
a
l: first p
u
b
lish
e
d
a
s 1
0
.1
1
3
6
/b
m
jo
q
-2
0
1

7
-0
0
0
2
8
1
o
n
2
0
A
p
ril 2
0
1
8
. D
o
w
n
lo
a
d
e
d

fro
m
http://creativecommons.org/licenses/by-nc/4.0/
http://creativecommons.org/licenses/by-nc/4.0/
http://www.bmj.com/company/products-services/rights-and-
licensing/
http://www.bmj.com/company/products-services/rights-and-
licensing/
http://dx.doi.org/10.1136/bmj.i2139
http://dx.doi.org/10.1136/bmj.333.7561.220-f
http://dx.doi.org/10.7326/0003-4819-158-5-201303051-00006
http://dx.doi.org/10.1111/ijcp.12701
http://dx.doi.org/10.1001/archinte.165.16.1842
http://dx.doi.org/10.7326/0003-4819-138-3-200302040-00007
https://psnet.ahrq.gov/primers/primer/1/medication-
https://psnet.ahrq.gov/primers/primer/1/medication-
http://dx.doi.org/10.2146/ajhp080552
http://www.ncbi.nlm.nih.gov/pubmed/12434722
http://dx.doi.org/10.1111/j.1365-2753.2008.01000.x
http://bmjopenquality.bmj.com/Improving medication
reconciliation at hospital admission, discharge and ambulatory
care through a transition of
care teamAbstractProblemBackgroundBaseline
measurementDesignStrategyPlan-Do-Study-Act 1—education—
June 2016Plan-Do-Study-Act 2—Transition of Care Team
implemented—November 2016ResultsLessons and
limitationsConclusionReferences
Contents lists available at ScienceDirect

Research in Social and Administrative Pharmacy
journal homepage: www.elsevier.com/locate/rsap
Impact of medication reconciliation on health outcomes: An
overview of
systematic reviews
A.B. Guisado-Gila,b,∗ , M. Mejías-Truebaa, E.R. Alfaro-Laraa,
M. Sánchez-Hidalgob,
N. Ramírez-Duquec, M.D. Santos-Rubiod
a Unidad de Gestión Clínica Farmacia. Hospital Universitario
Virgen del Rocío, Sevilla, Spain
b Departamento de Farmacología. Facultad de Farmacia,
Universidad de Sevilla, Sevilla, Spain
c Unidad de Gestión Clínica Medicina Interna. Hospital
Universitario Virgen del Rocío, Sevilla, Spain
d Unidad de Gestión Clínica Farmacia. Hospital Juan Ramón
Jiménez, Huelva, Spain
A R T I C L E I N F O
Keywords:
Systematic review
Medication reconciliation
Outcome assessment
Evidence-based practice
A B S T R A C T
Background: Recent systematic reviews and meta-analyses
suggest that medication reconciliation (MR) is ef-
fective in decreasing the risk of medication discrepancies.
Nevertheless, the association between MR and sub-
sequent improved healthcare outcomes is not well established.
Objectives: This systematic review of reviews set out to identify

published systematic reviews on the impact of
MR programs on health outcomes and to describe key
components of the intervention, the health outcomes
assessed and any associations between MR and health outcomes.
Methods: PubMed, EMBASE, Cochrane Library, Cumulative
Index to Nursing and Allied Health Literature
(CINAHL) and SCOPUS were searched from inception to May
2019. Systematic reviews of all study designs,
populations, intervention providers and settings that measured
patient-related outcomes or healthcare utiliza-
tion were considered. Methodological quality was assessed
using A Measurement Tool to Assess Systematic Reviews
2 (AMSTAR 2). Two investigators performed study selection,
quality assessment and data collection in-
dependently.
Results: Five systematic reviews met the inclusion criteria: 2
were rated as low quality and 3 as critically low
quality. Reviews included primary studies in different settings
(hospitals, the community and residential aged
care facilities) that reported the impact of MR on mortality,
length of stay, Emergency Department (ED) visits,
readmissions, physician visits and healthcare utilization. Only
one review reported results on mortality.
However, healthcare utilization, which usually included ED
visits and readmissions, was communicated in all
reviews. Meta-analyses were conducted in all reviews except
one. Medication reconciliation was not consistently
found to be associated with improvements in health outcomes.
Conclusions: Few systematic reviews support the value of MR
in achieving good patient-related outcomes and
healthcare utilization improvements. The quality of the
systematic reviews was low and the primary studies
included commonly involved additional activities related to MR.
There was no clear evidence in favor of in-
tervention in mortality, length of stay, ED visits, unplanned
readmissions, physician visits and healthcare uti-

lization.
Introduction
Care transitions are described as changes in care settings. Poor
quality transitions may result in risks to patients’ safety,
discontinuity
in care plans and patient dissatisfaction with care.1 Therefore,
transi-
tional care interventions encourage positive healthcare goals,2
require
coordination with healthcare professionals in both primary and
sec-
ondary care, and provide patients with accessible information
on post-
transition.3 In this context, the process of medication
reconciliation
should account for any alteration made in the medication taken
by
patients, and should ensure that patients or their caregivers have
been
made aware of these alterations.4
According to the Institute for Healthcare Improvement,
medication
reconciliation (MR) refers to the process of identifying the most
accu-
rate list of all medications a patient is taking and using this list
to
provide correct medications for patients anywhere within the
health
https://doi.org/10.1016/j.sapharm.2019.10.011
Received 13 July 2019; Received in revised form 1 October
2019; Accepted 15 October 2019

∗ Corresponding author. Unidad de Gestión Clínica Farmacia.
Hospital Universitario Virgen del Rocío, Avenida Manuel
Siurot, 41013, Sevilla, Spain.
E-mail address: [email protected] (A.B. Guisado-Gil).
Research in Social and Administrative Pharmacy xxx (xxxx)
xxx–xxx
1551-7411/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: A.B. Guisado-Gil, et al., Research in
Social and Administrative Pharmacy,
http://www.sciencedirect.com/science/journal/15517411
https://www.elsevier.com/locate/rsap
mailto:[email protected]
system.4 This review process identifies medication
discrepancies. Un-
intended medication discrepancies that represent reconciliation
errors
are responsible for more than half the medication errors
occurring
during transitions in care, and up to one-third could potentially
cause
harm.5
Previous primary research studies have evaluated the effect of
MR
on medication discrepancies, patient-related outcomes and

healthcare
utilization during care transitions. However, interpreting the
evidence
in relation to the impact of MR is a challenge due to the
variation in
study designs, interventions and settings. In recent years, a
growing
number of systematic reviews and meta-analyses relevant to the
impact
of MR on health outcomes have been published. Their results
suggest
that MR provided by pharmacists is effective in decreasing the
risk of
medication discrepancies.6–8 Nevertheless, the association
between MR
and the improvement in health outcomes, while plausible, is not
well
established. An overview of systematic reviews can play a role
in
summarizing existing research or highlighting the absence of
evidence,
improving access to specific information and supporting
decision-
making by clinicians, policy makers and developers of clinical
guide-
lines.9 The Cochrane Collaboration recommends an overview of
sys-
tematic reviews to summarize the evidence of existing
systematic re-
views that address different outcomes for a single
intervention.10
A previous overview of systematic reviews has measured the
impact
of MR on health outcomes.11 This overview, conducted by
Holte et al.

and published in 2015, considered health-related outcomes
(read-
missions, adverse events and unwanted events), but also
outcomes re-
lated to the process of performing medication reconciliation
(percen-
tage performing medication reconciliation and medication
discrepancies). It included seven moderate-quality systematic
reviews
which concluded that MR probably reduces the number of
medication
discrepancies, but that the impact on clinical outcomes is
unclear.
Neither publication specifically focuses on the impact of MR on
patient-
related outcomes and healthcare utilization. Moreover, this
overview
did not consider recent systematic reviews of MR.
The objectives of this overview were to identify published sys-
tematic reviews on the impact of MR programs on health
outcomes and
to describe key components of the intervention, the health
outcomes
assessed and any associations between MR and health outcomes.
Methods
Eligibility criteria
This systematic review was conducted in accordance with the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses
(PRISMA) guidelines.12 The completed PRISMA checklist is
included as
Supplementary File 1. Inclusion criteria according to PICOS

(Popula-
tion, Intervention, Comparison, Outcome and Study design) for
the
systematic review were:
Population: adults and/or pediatric patients experiencing a
transition of care.
Intervention: medication reconciliation. The intervention
involved a
healthcare professional and was performed before, during or
after a
care transition.
Comparison: a control group that received usual care.
Outcomes (at least one of the following): patient-related
outcomes
(mortality) and healthcare utilization (length of stay, unplanned
readmissions, Emergency Department visits and/or primary or
sec-
ondary care visits).
Study design: systematic reviews.
We excluded reviews investigating additional interventions not
fo-
cused on MR. Those exclusively reporting other outcomes
(medication
discrepancies, adverse drug events [ADEs] with potential to
cause in-
jury, preventable ADEs, medication adherence and
unanticipated in-
creased workload) were also excluded.
Information sources
An electronic literature search was performed using 5
Healthcare

Databases: PubMed, EMBASE, Cochrane Library, Cumulative
Index to
Nursing and Allied Health Literature (CINAHL) and SCOPUS,
with no
language or publication date restrictions up to 30 September
2018.
Search terms included a mixture of MeSH terms and free text
(key-
words, synonyms and word variations) combined with Boolean
opera-
tors. Filters were used to limit the results of the search to
systematic
reviews (see Table 1 for the complete search strategy). The last
full
search was run on 1 May 2019 in order to identify new results.
Study selection
Two independent reviewers (ABGG and MMT) screened the
titles
and abstracts of all eligible reviews for possible inclusion, with
any
disagreements settled by consensus or with a third reviewer
(ERAL).
Where there was uncertainty, full-length publications were
evaluated
before a final decision on inclusion was made.
Quality assessment
The quality-assessment tool known as A Measurement Tool to
Assess
Systematic Reviews 2 (AMSTAR 2)13 was used to assess the
quality and
risk of bias in the studies included. It consists of 16 items
whose re-

sponse options were “yes”, “no” or “partial yes”. Items 4, 7, 11,
13 and
15 are considered critical domains. The overall quality can be
rated as
high (no or one non-critical weakness), moderate (more than
one non-
critical weakness), low (one critical flaw with or without non-
critical
weakness), and critically low (more than one critical flaw with
or
without non-critical weakness). Two independent reviewers
(ABGG and
MMT) conducted the quality assessment, and any disagreements
on
quality ratings between reviewers were discussed and a
consensus
reached.
Table 1
Complete search strategy for different databases.
Healthcare Databases Search strategy
PubMed (“medication discrepancies” [All Fields] OR
“reconciliation discrepancies” [All Fields] OR (“medication
reconciliation” [MeSH Terms] OR “medication
reconciliation” [All Fields])) AND ((“impact” [All Fields] OR
“health outcomes” [All Fields] OR “Health Impact Assessment”
[Mesh] AND systematic
[sb]))
EMBASE (“health outcomes”/exp OR “health outcomes”) AND
(“medication therapy management”/exp OR “medication therapy
management”) AND [systematic
review]/lim

Cochrane Library “effect”:ti,ab, kw and
“reconciliation”:ti,ab,kw
Limits: Cochrane Reviews
CINAHL AB (medication reconciliation) AND (AB health
outcomes OR AB impact or effect or influence or AB outcome
or result or consequence)
Type of publication: systematic review
SCOPUS (impact OR effect OR health AND outcome) AND
(medication AND reconciliation OR reconciliation AND
discrepancies) AND (LIMIT-TO
(DOCTYPE,“re”)) AND (LIMIT-TO (SUBJAREA,“HEAL”))
A.B. Guisado-Gil, et al. Research in Social and Administrative
Pharmacy xxx (xxxx) xxx–xxx
2
Data collection
Reviewer ABGG independently extracted data and MMT
examined
all extraction sheets to ensure their accuracy. We also directly
com-
municated with the authors to obtain details not included in the
pub-
lished reports. If there were any missing data from a review, we
ex-
plicitly stated this. For each systematic review, the following
variables
were registered:
- Author and year of publication.

- Aim of systematic review.
- Number of primary studies.
- Design of primary studies: randomized controlled trial (RCT),
pro-
spective controlled trial, before-and-after, cohort study,
observa-
tional post-intervention, retrospective observational and cross-
sec-
tional studies.
- Number of participants.
- Type of participants: adults and/or pediatric patients.
- Settings and transitions of care involved.
- Intervention providers: pharmacists, nurses and/or physicians.
- Key components of intervention.
- Health outcomes: mortality, length of stay, unplanned
readmissions,
Emergency Department visits and primary and secondary care
visits.
- Other outcomes collected in systematic reviews: medication
dis-
crepancies, ADEs with potential to cause injury, preventable
ADEs,
medication adherence and unanticipated increased workload.
Both narrative findings and meta-analyses of primary study data
included in the systematic reviews were synthesized. The
measures of
association between MR and health outcomes included the risk
ratio
(RR) and difference in means (MD), with consistency (I2)
reported by
individual reviews and meta-analyses.

Results
The electronic search revealed 86 citations; 8 were removed
using
Mendeley via duplicate checking. Additionally, 56 reviews were
ex-
cluded following title and abstract filtering because they did not
meet
the eligibility criteria. This left 22 reviews that were potentially
re-
levant and retrieved in full-text: 17 were excluded before data
extrac-
tion and 5 met the inclusion criteria (Fig. 1). A list of the 17
publica-
tions excluded after full-text evaluation and the reasons for
exclusion
are provided in Supplementary File 2.
Quality of the systematic reviews
Table 2 reports on the AMSTAR 2 response option for each
domain.
The overall quality of the included studies assessed with
AMSTAR 2 was
poor. Of the 5 reviews, none was rated as high or moderate
quality, 2
were rated as low quality,15,17 and 3 were critically low
quality.7,14,16
All reviews presented similarities with respect to responses in
cri-
tical and non-critical domains, except for Lehnbom et al.14 who
did not
carry out a meta-analysis. Regarding non-critical flaws, none
showed

that they had worked with a written protocol with independent
ver-
ification before the review was undertaken (item 2), or
documented the
funding sources for each study included in the review (item 10),
except
Redmond et al.17 As for critical flaws, none provided a
complete list of
potentially relevant studies with justification for the exclusion
each one
(item 7). Redmond et al.17 only included a selection of their
excluded
articles. In addition, Lehnbom et al.14 did not assess the risk of
bias
(RoB) in individual studies or include a discussion of its impact
on the
interpretation of the results (item 13) and, together with the
other two
critically low quality reviews,7,16 did not perform a sensitivity
analysis
to determine publication of bias (item 15).
Characteristics of included systematic reviews and meta-
analyses
Full details of the included studies are shown in Table 3. All the
review articles7,14–17 aimed to identify MR interventions and
to test
their association with clinical outcomes. One of them14 also
evaluated
separately the effectiveness of medication review. They
included vari-
able numbers of primary studies: Kwan et al.7 18 studies,
Lehnbom
et al.14 40 studies, McNab et al.15 14 studies, Cheema et al.16
18 studies

and Redmond et al.17 25 studies. The 5 reviews cited a
combined total
of 87 original research articles: 40 RCTs, 4 prospective
controlled trials,
7 before-and-after, 9 cohort studies, 22 observational post-
intervention,
3 retrospective observational and 2 cross-sectional studies. In
total,
65912 patients were studied, with people recruited from
hospitals, from
the community and from residential aged care facilities (RACF).
Despite
contacting the authors, McNab et al.15 were unable to provide
data on
the number of patients enrolled and the number of participants
under
18, in two studies included in their review.
Pharmacists were primarily responsible for delivering the inter-
vention, working closely with other healthcare professionals
(physi-
cians and nurses) in some cases.7,14,17 Interventions beyond
MR in-
cluded patient counselling,7,14,16,17 creation of post-discharge
medication lists,7,14,16,17 post-discharge
communication7,14,17 and
medication review.17 Reviews reported the control group's
intervention
to consist of usual care in the context in which the study took
place,
except in two studies18,19 included in Kwan et al.'s
publication,7 which
compared two forms of MR.
The reviews included a combined total of 37 primary research
studies that reported the impact of MR on different health

outcomes:
mortality,17 length of stay,14,17 Emergency Department
visits,14,15,17
readmissions14,15,17 and physician visits,14,15 without
restrictions on
follow-up periods. All reviews7,14–17 also studied the impact
of MR on
healthcare utilization, a composite variable made up of two or
more
health measures. Meta-analysis was conducted except in one
case14 if
available data allowed pooling of results, and the variables
measured
were homogenous. Additional outcomes identified were:
medication
discrepancies,14–17 ADEs with potential to cause injury,7,16
preventable
ADEs,16,17 medication adherence17 and primary care
workload.15
Effectiveness of medication reconciliation on health outcomes
(see Table 4)
Mortality
One review17 reported mortality with no statistically significant
differences between MR and standard care (RR 0.75, 95% CI
0.27 to
2.08) based on the results of one RCT.
Length of stay
Two reviews14,17 reported no statistically significant
differences
between MR in hospitals and standard care regarding length of

stay.
Pooled results of 2 RCTs included in the meta-analysis
performed by
Redmond et al.17 were MD 0.48 (95% CI -1.04 to 1.99) with
some
evidence of heterogeneity between these studies (I2 = 52%; p =
0.15).
Medication reconciliation in RACF demonstrated significantly
shorter
hospital stays (p = 0.026) according to one before-and-after
study in-
cluded by Lehnbom et al.14
Emergency Department visits
In relation to the hospital setting, Lehnbom et al.14
communicated
no statistically significant differences regarding ED visits
within 72 h,
14 days or 30 days after discharge based on the results of one
before-
and-after study, whereas Redmond et al.17 included the results
of one
small RCT with a moderate risk of bias that reported reduced
ED visits
within 30 days after discharge (RR 0.07, 95% CI 0.00 to 1.07).
On the
other hand, McNab et al.15 included 2 non-RCTs with no
difference
observed between groups, indicating no clear effect of MR on
ED visit
rates.

3
Unplanned readmissions
Two reviews14,17 communicated no statistically significant
differ-
ences regarding unplanned rehospitalization rates in the hospital
set-
ting. The pooled results of 5 RCTs included in the meta-analysis
per-
formed by Redmond et al.17 were RR 0.72 (95% CI 0.44 to
1.18) with a
follow-up range of 5–30 days and some evidence of
heterogeneity be-
tween these studies (I2 = 45%; p = 0.12). In the community
setting,
Lehnbom et al.14 included one cohort study where the
readmissions rate
decreased at 7 (p = 0.01) and 14 days (p = 0.04) but not at 30
days
(p = 0.29) after discharge. McNab et al.15 included 7 studies in
the
meta-analysis (4 RCTs and 3 cohort studies), and the pooled RR
was
0.91 (95% CI 0.66 to 1.25) with high heterogeneity (I2 = 71%;
p = 0.002). The follow-up period was 30 days, except in 2 RCTs
in
which it was 6 months.
Physician visits
One prospective controlled study in the community setting
included
by Lehnbom et al.14 found that control patients had a lower rate

of
discrepancy resolution and reported no significant trend towards
more
planned and unplanned physician visits compared with
intervention
patients. One RCT in McNab et al.'s review15 reported a
significant
increase in general practitioner visits of 43% (p = 0.002) in the
MR
group, while another RCT reported no significant difference at
6
months.
Healthcare utilization
Healthcare utilization after hospital discharges usually included
ED
visits and readmissions. In this respect, reported data from 4
RCTs in-
cluded in Cheema et al.'s meta-analysis16 showed no significant
reduction in favor of the MR group, with a pooled RR of 0.78
(95% CI
0.61 to 1.00) and no heterogeneity between the studies (I2 =
0%;
p = 0.54). Four RCTs included in Redmond et al.'s meta-
analysis17 re-
ported no certainty of the effect of the intervention (RR 0.78,
95% CI
0.50 to 1.22) and some evidence of heterogeneity (I2 = 48%; p
= 0.12).
On the contrary, the pooled results from 3 RCTs from Kwan et
al.'s
meta-analysis7 achieved a statistically significant reduction in
health-
care usage (RR 0.77, 95% CI 0.63 to 0.95), but heterogeneity

was not
assessed. Medication reconciliation by a clinical pharmacist at
admis-
sion, and medication review by a clinical pharmacist during
hospitali-
zation, also offered no improvements in terms of number of ED
visits,
hospital readmissions and mortality rates compared with
standard care,
according to one prospective controlled study included by
Lehnbom
et al.14 However, in RACF one RCT reported fewer ED visits
and
readmissions (p = 0.035) when compared to control patients.
McNab
et al.15 communicated the results of 2 articles (1 RCT and 1
before-and-
after study) which measured healthcare utilization as
readmissions and
ED or general practitioner visits, with no statistically
significant dif-
ferences between groups.
Discussion
This is the first overview of systematic reviews that specifically
fo-
cuses on the impact of MR on patient-related outcomes and
healthcare
utilization. Two independent reviewers systematically reviewed
the
literature with no publication date or language restrictions, and
eval-
uated the quality of the systematic reviews using the review
instrument
AMSTAR 213 validated for randomized or non-randomized

studies of
healthcare interventions, and extracted data from the
publications
Fig. 1. Preferred Reporting Items for Systematic Reviews and
Meta-Analyses literature search and study selection
flowchart.12
4
Ta
bl
e
2
Q
ua
lit
y
of
sy
st
em
at
ic
re

vi
ew
s
ba
se
d
on
th
e
16
-it
em
A
M
ST
A
R
2
Ch
ec
kl
is
t.1
3

Ite
m
Kw
an
et
al
.2
01
37
Le
hn
bo
m
et
al
.2
01
41
4
M
cN
ab
et
al

.
20
18
15
Ch
ee
m
a
et
al
.2
01
81
6
Re
dm
on
d
et
al
.2
01
81
7

1.
D
id
th
e
re
se
ar
ch
qu
es
tio
ns
an
d
in
cl
us
io
n
cr
ite
ri
a

fo
r
th
e
re
vi
ew
in
cl
ud
e
th
e
co
m
po
ne
nt
s
of
PI
CO
?
Ye

s
Ye
s
Ye
s
Ye
s
Ye
s
2.
D
id
th
e
re
po
rt
of
th
e
re
vi
ew
co

nt
ai
n
an
ex
pl
ic
it
st
at
em
en
t
th
at
th
e
re
vi
ew
m
et
ho
ds

w
er
e
es
ta
bl
is
he
d
pr
io
r
to
th
e
co
nd
uc
t
of
th
e
re
vi

ew
,a
nd
,d
id
th
e
re
po
rt
ju
st
ify
an
y
si
gn
ifi
ca
nt
de
vi
at
io

ns
fr
om
th
e
pr
ot
oc
ol
?
Pa
rt
ia
ly
es
Pa
rt
ia
ly
es
Pa
rt
ia
ly

es
Pa
rt
ia
ly
es
Ye
s
3.
D
id
th
e
re
vi
ew
au
th
or
s
ex
pl
ai
n

th
ei
r
se
le
ct
io
n
of
th
e
st
ud
y
de
si
gn
s
fo
r
in
cl
us
io

n
in
th
e
re
vi
ew
?
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
4.
D
id
th
e
re

vi
ew
au
th
or
s
us
e
a
co
m
pr
eh
en
si
ve
lit
er
at
ur
e
se
ar
ch

st
ra
te
gy
?
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
5.
D
id
th
e
re
vi
ew
au

th
or
s
pe
rf
or
m
st
ud
y
se
le
ct
io
n
in
du
pl
ic
at
e?
Ye
s
Ye

s
Ye
s
Ye
s
Ye
s
6.
D
id
th
e
re
vi
ew
au
th
or
s
pe
rf
or
m
da

ta
ex
tr
ac
tio
n
in
du
pl
ic
at
e?
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
7.
D

id
th
e
re
vi
ew
au
th
or
s
pr
ov
id
e
a
lis
t
of
ex
cl
ud
ed
st
ud

ie
s
an
d
ju
st
ify
th
e
ex
cl
us
io
ns
?
N
o
N
o
N
o
N
o
N

o
8.
D
id
th
e
re
vi
ew
au
th
or
s
de
sc
ri
be
th
e
in
cl
ud
ed
st

ud
ie
s
in
ad
eq
ua
te
de
ta
il?
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
9.
D
id

th
e
re
vi
ew
au
th
or
s
us
e
a
sa
tis
fa
ct
or
y
te
ch
ni
qu
e
fo

r
as
se
ss
in
g
th
e
Ro
B
in
in
di
vi
du
al
st
ud
ie
s
th
at
w
er

e
in
cl
ud
ed
in
th
e
re
vi
ew
?
Ye
s
N
o
Ye
s
Ye
s
Ye
s
10
.D

id
th
e
re
vi
ew
au
th
or
s
re
po
rt
th
e
so
ur
ce
s
of
fu
nd
in
g

fo
r
th
e
st
ud
ie
s
in
cl
ud
ed
in
th
e
re
vi
ew
?
N
o
N
o
N

o
N
o
Ye
s
11
.I
fm
et
a-
an
al
ys
is
w
as
pe
rf
or
m
ed
,d
id
th

e
re
vi
ew
au
th
or
s
us
e
ap
pr
op
ri
at
e
m
et
ho
ds
fo
r
th
e

st
at
is
tic
al
co
m
bi
na
tio
n
of
re
su
lts
?
Ye
s
N
o
m
et
a-
an

al
ys
is
co
nd
uc
te
d
Ye
s
Ye
s
Ye
s
12
.I
fm
et
a-
an
al
ys
is
w

as
pe
rf
or
m
ed
,d
id
th
e
re
vi
ew
au
th
or
s
as
se
ss
th
e
po
te

nt
ia
li
m
pa
ct
of
Ro
B
in
in
di
vi
du
al
st
ud
ie
s
on
th
e
re
su

lts
of
th
e
m
et
a-
an
al
ys
is
or
ot
he
r
ev
id
en
ce
sy
nt
he
si
s?

Ye
s
N
o
m
et
a-
an
al
ys
is
co
nd
uc
te
d
Ye
s
Ye
s
Ye
s
13
.D

id
th
e
re
vi
ew
au
th
or
sa
cc
ou
nt
fo
rR
oB
in
in
di
vi
du
al
st
ud

ie
sw
he
n
in
te
rp
re
tin
g/
di
sc
us
si
ng
th
e
re
su
lts
of
th
e
re

vi
ew
?
Ye
s
N
o
Ye
s
Ye
s
Ye
s
14
.D
id
th
e
re
vi
ew
au
th
or

s
pr
ov
id
e
a
sa
tis
fa
ct
or
y
ex
pl
an
at
io
n
fo
r,
an
d
di
sc

us
si
on
of
,a
ny
he
te
ro
ge
ne
ity
ob
se
rv
ed
in
th
e
re
su
lts
of
th

e
re
vi
ew
?
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
15
.I
ft
he
y
pe
rf
or

m
ed
qu
an
tit
at
iv
e
sy
nt
he
si
s,
di
d
th
e
re
vi
ew
au
th
or
s

ca
rr
y
ou
ta
n
ad
eq
ua
te
in
ve
st
ig
at
io
n
of
pu
bl
ic
at
io
n

bi
as
(s
m
al
ls
tu
dy
bi
as
)
an
d
di
sc
us
s
its
lik
el
y
im
pa
ct

on
th
e
re
su
lts
of
th
e
re
vi
ew
?
N
o
N
o
m
et
a-
an
al
ys
is

co
nd
uc
te
d
Ye
s
N
o
Ye
s
16
.D
id
th
e
re
vi
ew
au
th
or
s
re

po
rt
an
y
po
te
nt
ia
ls
ou
rc
es
of
co
nfl
ic
to
fi
nt
er
es
t,
in
cl

ud
in
g
an
y
fu
nd
in
g
th
ey
re
ce
iv
ed
fo
r
co
nd
uc
tin
g
th
e

re
vi
ew
?
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
Q
ua
lit
y
le
ve
l
Cr
iti
ca

lly
lo
w
Cr
iti
ca
lly
lo
w
Lo
w
Cr
iti
ca
lly
lo
w
Lo
w
a A
M
ST
A

R
=
A
ss
es
sm
en
t
of
M
ul
tip
le
Sy
st
em
at
ic
Re
vi
ew
s.
PI
CO

=
Po
pu
la
tio
n,
In
te
rv
en
tio
n,
Co
m
pa
ri
so
n,
O
ut
co
m
e.
Ro

B
=
ri
sk
of
bi
as
.
5
Ta
bl
e
3
Su
m
m
ar
y
of
ch
ar

ac
te
ri
st
ic
s
of
se
le
ct
ed
sy
st
em
at
ic
re
vi
ew
s
an
d
m
et

a-
an
al
ys
es
.
A
ut
ho
r,
ye
ar
A
im
N
um
be
r
an
d
de
si
gn
of

st
ud
ie
s
N
um
be
r
an
d
ty
pe
of
pa
rt
ic
ip
an
ts
Se
tt
in
g
(t

ra
ns
iti
on
po
in
t)
In
te
rv
en
tio
n
pr
ov
id
er
In
te
rv
en
tio
n
H

ea
lth
ou
tc
om
es
O
th
er
ou
tc
om
es
Kw
an
et
al
.
20
13
7
To
su
m

m
ar
iz
e
ev
id
en
ce
on
th
e
eff
ec
tiv
en
es
s
of
ho
sp
ita
l-b
as
ed

M
R
in
te
rv
en
tio
ns
5
RC
Ts
4
be
fo
re
-a
nd
-a
fte
r
9
po
st
-

in
te
rv
en
tio
n
39
17
0
ad
ul
ts
29
5
pe
di
at
ri
c
pa
tie
nt
s

H
os
pi
ta
l(
ad
m
is
si
on
,
di
sc
ha
rg
e
ho
m
e,
in
-
ho
sp
ita

lt
ra
ns
fe
r)
Ph
ar
m
ac
is
ts
A
ls
o
ph
ys
ic
ia
ns
an
d
nu
rs
es

M
R
Pa
tie
nt
co
un
se
lli
ng
Cr
ea
tio
n
of
po
st
-
di
sc
ha
rg
e
m

ed
ic
at
io
n
lis
ts
Po
st
-d
is
ch
ar
ge
co
m
m
un
ic
at
io
n
H
ea

lth
ca
re
ut
ili
za
tio
n
(E
m
er
ge
nc
y
D
ep
ar
tm
en
t
vi
si
ts
an

d
re
ad
m
is
si
on
w
ith
in
30
da
ys
)
Cl
in
ic
al
ly
si
gn
ifi
ca
nt

un
in
te
nd
ed
m
ed
ic
at
io
n
di
sc
re
pa
nc
ie
s
(e
qu
al
to
A
D

Es
w
ith
po
te
nt
ia
lt
o
ca
us
e
in
ju
ry
)
Le
hn
bo
m
et
al
.
20

14
14
To
ev
al
ua
te
ho
w
eff
ec
tiv
e
M
R
an
d
m
ed
ic
at
io
n
re

vi
ew
ar
e
in
id
en
tif
yi
ng
an
d
re
ct
ify
in
g
ha
rm
fu
ld
is
cr
ep

an
ci
es
an
d
m
ed
ic
at
io
n-
re
la
te
d
pr
ob
le
m
s,
an
d
to
as

se
ss
th
ei
r
im
pa
ct
on
cl
in
ic
al
ou
tc
om
es
5
RC
Ts
4
pr
os

pe
ct
iv
e
co
nt
ro
lle
d
2
be
fo
re
-a
nd
-a
fte
r
3
co
ho
rt
21
po

st
-
in
te
rv
en
tio
n
3
re
tr
os
pe
ct
iv
e
ob
se
rv
at
io
na
l
2

cr
os
s-
se
ct
io
na
l
19
15
8
ad
ul
ts
H
os
pi
ta
l(
ad
m
is
si
on

,
di
sc
ha
rg
e
ho
m
e,
in
-
ho
sp
ita
lt
ra
ns
fe
r)
Co
m
m
un
ity

(d
is
ch
ar
ge
fr
om
ho
sp
ita
lt
o
ho
m
e)
RA
CF
(a
dm
is
si
on
fr
om

ho
sp
ita
l)
Ph
ar
m
ac
is
ts
A
ls
o
ph
ys
ic
ia
ns
an
d
nu
rs
es
M

R
Pa
tie
nt
co
un
se
lli
ng
Cr
ea
tio
n
of
po
st
-
di
sc
ha
rg
e
m
ed

ic
at
io
n
lis
ts
Po
st
-d
is
ch
ar
ge
co
m
m
un
ic
at
io
n
Em
er
ge

nc
y
D
ep
ar
tm
en
tv
is
its
Re
ad
m
is
si
on
s
Le
ng
th
of
st
ay
Ph

ys
ic
ia
n
vi
si
ts
H
ea
lth
ca
re
ut
ili
za
tio
n
(E
m
er
ge
nc
y
D

ep
ar
tm
en
tv
is
its
,
re
ad
m
is
si
on
s
an
d
m
or
ta
lit
y)
M
ed

ic
at
io
n
di
sc
re
pa
nc
ie
s
M
cN
ab
et
al
.
20
18
15
To
de
te

rm
in
e
th
e
eff
ec
tiv
en
es
s
of
M
R
in
ov
er
al
ld
is
cr
ep
an
cy

id
en
tifi
ca
tio
n
an
d
re
so
lu
tio
n,
th
e
cl
in
ic
al
re
le
va
nc
e

of
re
so
lv
ed
di
sc
re
pa
nc
ie
s
an
d
he
al
th
ca
re
ut
ili
za
tio
n

5
RC
Ts
3
be
fo
re
-a
nd
-a
fte
r
6
co
ho
rt
36
42
ad
ul
ts
an
d
pe

di
at
ri
c
pa
tie
nt
s
Co
m
m
un
ity
(d
is
ch
ar
ge
fr
om
ho
sp
ita
lt

o
ho
m
e,
re
si
de
nt
ia
lu
ni
t
or
nu
rs
in
g
ho
m
e)
Ph
ar
m
ac

is
ts
M
R
Em
er
ge
nc
y
D
ep
ar
tm
en
tv
is
its
Re
ad
m
is
si
on
s

Pr
im
ar
y
an
d
se
co
nd
ar
y
ca
re
co
ns
ul
ta
tio
ns
M
ed
ic
at
io

n
di
sc
re
pa
nc
ie
s
Pr
im
ar
y
ca
re
w
or
kl
oa
d
Ch
ee
m
a
et

al
.
20
18
16
To
up
da
te
th
e
ex
is
tin
g
ev
al
ua
tio
n
of
th
e
im

pa
ct
of
ph
ar
m
ac
is
t-l
ed
m
ed
ic
at
io
n
re
co
nc
ili
at
io
n
on

he
al
th
ca
re
ou
tc
om
es
18
RC
Ts
60
38
ad
ul
ts
H
os
pi
ta
l(
ad
m

is
si
on
,
di
sc
ha
rg
e
ho
m
e,
in
-
ho
sp
ita
lt
ra
ns
fe
r)
Ph
ar

m
ac
is
ts
M
R
Pa
tie
nt
co
un
se
lli
ng
Cr
ea
tio
n
of
po
st
-
di
sc

ha
rg
e
m
ed
ic
at
io
n
lis
ts
H
ea
lth
ca
re
ut
ili
za
tio
n
(d
ru

g-
re
la
te
d
Em
er
ge
nc
y
D
ep
ar
tm
en
t
vi
si
ts
an
d
re
ad
m

is
si
on
s)
M
ed
ic
at
io
n
di
sc
re
pa
nc
ie
s
A
D
Es
w
ith
po
te

nt
ia
lt
o
ca
us
e
in
ju
ry
Pr
ev
en
ta
bl
e
A
D
Es
Re
dm
on
d
et

al
.
20
18
17
To
as
se
ss
th
e
eff
ec
t
of
M
R
on
m
ed
ic
at
io
n

di
sc
re
pa
nc
ie
s,
pa
tie
nt
-r
el
at
ed
ou
tc
om
es
an
d
he
al
th
ca

re
ut
ili
za
tio
n
in
pe
op
le
re
ce
iv
in
g
th
is
in
te
rv
en
tio
n
du

ri
ng
ca
re
tr
an
si
tio
ns
25
RC
Ts
69
95
ad
ul
ts
H
os
pi
ta
l(
ad
m

is
si
on
,
di
sc
ha
rg
e
ho
m
e,
in
-
ho
sp
ita
lt
ra
ns
fe
r)
Co
m

m
un
ity
(d
is
ch
ar
ge
fr
om
ho
sp
ita
lt
o
ho
m
e)
RA
CF
(a
dm
is
si

on
fr
om
ho
sp
ita
l)
Ph
ar
m
ac
is
ts
A
ls
o
ph
ys
ic
ia
ns
an
d
nu

rs
es
M
R
Pa
tie
nt
co
un
se
lli
ng
M
ed
ic
at
io
n
in
fo
rm
at
io
n

Po
st
-tr
an
si
tio
n
co
m
m
un
ic
at
io
n
M
ed
ic
at
io
n
re
vi
ew

Le
ng
th
of
st
ay
M
or
ta
lit
y
Em
er
ge
nc
y
D
ep
ar
tm
en
tv
is
its

Re
ad
m
is
si
on
s
H
ea
lth
ca
re
ut
ili
za
tio
n
(E
m
er
ge
nc
y
D

ep
ar
tm
en
t
vi
si
ts
an
d
re
ho
sp
ita
liz
at
io
n)
M
ed
ic
at
io
n

di
sc
re
pa
nc
ie
s
A
D
Es
w
ith
po
te
nt
ia
lt
o
ca
us
e
in
ju
ry

Pr
ev
en
ta
bl
e
A
D
Es
M
ed
ic
at
io
n
ad
he
re
nc
e
RC
Ts
=
Ra

nd
om
iz
ed
Co
nt
ro
lle
d
Tr
ia
ls
.M
R
=
M
ed
ic
at
io
n
re
co
nc

ili
at
io
n.
A
D
Es
=
ad
ve
rs
e
dr
ug
ev
en
ts
.R
A
CF
=
Re
si
de

nt
ia
la
ge
d
ca
re
fa
ci
lit
ie
s.
6
included. Medication reconciliation is proposed to avoid
possible
medication errors, and consequently harm to patients, however,
our
findings show that, compared with usual care, the intervention
does not
achieve a clear improvement for patient-related outcomes and
health-
care utilization.

The reviews included were low15,17 and critically low7,14,16
in
quality according to AMSTAR 213. The main results in critical
and non-
critical domains were consistent with Wolfe et al.20 Overall,
the most
frequent methodological shortcomings were: rarely providing
evidence
that the authors had worked with a written and registered
protocol with
independent verification; not providing a list of excluded
studies and
justification of exclusions; infrequently assessing the likelihood
of
publication bias, and neglecting to state the sources of funding
of each
primary study. A list of excluded studies and justification (item
7; cri-
tical domain) was necessary to qualify publications as moderate
quality.
However, it is currently rare when publishing systematic
reviews in
journals to include this information beyond the study selection
flow-
chart.
Of the 5 systematic reviews included, all conducted further
meta-
analyses except Lehnbom et al.14 For the meta-analysis, authors
used a
random effects model. This model, as opposed to a fixed-effects
model,
is advised in the case of statistical heterogeneity in studies.10
Ad-
ditionally, two reviews7,16 used a fixed model to validate their
results.

The results of this review are in line with other authors21,22
who
communicated that hospital-based care is the most commonly
studied
point of transition, follow by primary care and long-term care
settings.
Regarding intervention providers, the findings were consistent
with
Mueller et al.6 whose review found that the majority of, and
most
successful, interventions relied heavily on pharmacists.
Growing evi-
dence shows that medication lists obtained by pharmacists
contain
significantly fewer errors than those obtained through the usual
means.
In this sense, a new law in California, which came into effect on
1
January 2019, requires pharmacy staff at hospitals with more
than 100
beds to obtain an accurate medication list for each newly
admitted
high-risk patient.23
Most studies compared the intervention group with usual care,
but it
is not always clear what usual care involved. For ethical
reasons, most
studies failed to evaluate MR versus “no medication
reconciliation”,
thus limiting their ability to detect a significant difference
between
groups. In addition, all reviews except McNab et al.15 included
articles
that bundled MR with other interventions aimed at improving

transi-
tions of care, but the specific effect of MR in these multifaceted
inter-
ventions is not found. In this overview, MR does not achieve a
clear
improvement in health outcomes. Only one review17 based on a
single
publication reported results on mortality. However, the impact
of MR
on healthcare utilization was communicated in all reviews.7,14–
17
Emergency Department visits and readmissions were other
results with
a follow-up period no longer than 30 days in most studies. In
contrast, a
trial of MR with no additional discharge interventions that used
a
longer follow-up (12 months) reported a significant reduction in
ED
visits and readmissions.24 This suggests the convenience of
future re-
search to consider a time point beyond the traditional 30-day
mark.
The main strength of our study is that it was not limited to
specific
study designs, population, intervention providers, settings or
health
outcomes measured, and was intended to provide an outline of
current
evidence related to MR. The results summarize the effectiveness
of the
intervention on mortality, length of stay, ED visits, unplanned
read-

missions, physician visits and healthcare utilization. The main
limita-
tion is that the low number of systematic reviews included did
not make
it possible to exclude reviews with insufficient quality, and
moderate
and high quality systematic reviews in the literature that met the
in-
clusion criteria were not found. In addition, because of evidence
of
substantial heterogeneity in study designs, settings, intervention
com-
ponents and health outcomes, statistical pooling of all primary
studies
that measured health outcomes was not always possible. Even
those in
which a meta-analysis was carried out, the value of I2 showed a
non-
negligible level of heterogeneity.
While all reviews in our overview addressed the impact of MR
on
patient-related outcomes and healthcare utilization, a limitation
com-
monly admitted by the authors of the reviews included is that
few
primary research articles specifically focused on these results.
These
were often listed as secondary or composite outcomes, and the
studies
were not powered to detect a significant difference between
groups.
This means that it is difficult to draw definitive conclusions
from meta-
analysis, other than to say that there is currently no firm
evidence that

MR improves health outcomes. Further research is needed that
includes
more studies that are robust and of adequate sample size to test
the
impact of MR on health outcomes.
Conclusion
Few systematic reviews support the value of MR in achieving
good
patient-related outcomes and healthcare utilization
improvements. The
quality of the systematic reviews were low and the primary
studies
included, mostly RCTs, often involved additional activities
related to
MR. There was no clear evidence in favor of the intervention in
mor-
tality, length of stay, ED visits, unplanned readmissions,
physician visits
and healthcare utilization, the latter being the most frequently
com-
municated clinical outcome.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
None.
Acknowledgements
We would like to thank Fundación Andaluza Beturia para la

Investigación en Salud (FABIS) who provided critical review
and support
in writing this review.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.sapharm.2019.10.011.
Table 4
Association between medication reconciliation and health
outcomes.
Health outcomes Setting Number of
systematic
reviews
Number of
primary
studies
Association
Mortality Hospital 117 1 ND
Length of stay Hospital 214,17 3 ND
RACF 114 1 +
Emergency
Department
visits
Hospital 214,17 2 ND
Community 115 2 ND
Unplanned

readmissions
Hospital 214,17 6 ND
Community 214, 15 7 ND
Physician visits Community 214, 15 3 ‒/ND
Healthcare
utilization
Hospital 47, 14,16,17 10 +/ND
Community 115 2 ND
RACF 114 1 +
RACF = Residential aged care facilities. ND=No statistically
significant dif-
ferences (p > 0.05). + = Statistically significant differences in
favor of
medication reconciliation (p < 0.05). ‒ = Statistically
significant differences
against medication reconciliation (p < 0.05).
7
References
1. Moore C, McGinn T, Halm E. Tying up loose ends
discharging patients with un-
resolved medical issues. Arch Intern Med. 2007;167:1305–1311.
https://doi.org/10.

1001/archinte.167.12.1305.
2. Chenoweth L, Kable A, Pond D. Research in hospital
discharge procedures addresses
gaps in care continuity in the community, but leaves gaping
holes for people with
dementia: a review of the literature. Australas J Ageing.
2015;34:9–14. https://doi.
org/10.1111/ajag.12205.
3. Jack BW, Chetty VK, Anthony D, et al. A reengineered
hospital discharge program to
decrease rehospitalization: a randomized trial. Ann Intern Med.
2009;150:178–187.
https://doi.org/10.7326/0003-4819-150-3-200902030-00007.
4. Institute for Healthcare Improvement. Medication
Reconciliation Review. 2007; 2007
http://www.ihi.org/resources/Pages/Tools/MedicationReconcilia
tionReview.aspx
28.06.19.
5. Cornish PL, Knowles SR, Marchesano R, et al. Unintended
medication discrepancies
at the time of hospital admission. Arch Intern Med.
2005;165:424–429. https://doi.
org/10.1001/archinte.165.4.424.
6. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL.
Hospital-based medication re-
conciliation practices: a systematic review. Arch Intern Med.
2012;172:1057–1069.
https://doi.org/10.1001/archinternmed.2012.2246.
7. Kwan JL, Lo L, Sampson M, Shojania KG. Medication
reconciliation during transitions

of care as a patient safety strategy: a systematic review. Ann
Intern Med.
2013;158:397–403. https://doi.org/10.7326/0003-4819-158-5-
201303051-00006.
8. Mekonnen AB, McLachlan AJ, Brien JE. Effectiveness of
pharmacist-led medication
reconciliation programmes on clinical outcomes at hospital
transitions: a systematic
review and meta-analysis. BMJ Open. 2016;6.
https://doi.org/10.1136/bmjopen-
2015-010003 e010003.
9. Smith V, Devane D, Begley CM, Clarke M. Methodology in
conducting a systematic
review of systematic reviews of healthcare interventions. BMC
Med Res Methodol.
2011;11(1):15–21. https://doi.org/10.1186/1471-2288-11-15.
10. Higgins JPT, Thomas J, Chandler J, eds. Cochrane
Handbook for Systematic Reviews of
Interventions Version 6.0 (updated July 2019). Cochrane;
2019http://www.training.
cochrane.org/handbook, Accessed date: 29 September 2019.
11. Holte HH, Hafstad E, Vist GE. Overview of Reviews on
Effect of Medical Reconciliation
Oslo: National Knowledge Center for Health Service; 2015
Report from Knowledge
Center Nº 7-2015.
12. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting
items for systematic reviews
and meta-analyses: the PRISMA statement. PLoS Med. 2009;6.
https://doi.org/10.
1371/journal.pmed.1000097 e1000097.

13. Shea BJ, Reeves BC, Wells G, et al. Amstar 2: a critical
appraisal tool for systematic
reviews that include randomised or non-randomised studies of
healthcare
interventions, or both. BMJ. 2017;358:j4008.
https://doi.org/10.1136/bmj.j4008.
14. Lehnbom EC, Stewart MJ, Manias E, Westbrook JI. Impact
of medication re-
conciliation and review on clinical outcomes. Ann
Pharmacother.
2014;48:1298–1312.
https://doi.org/10.1177/1060028014543485.
15. McNab D, Bowie P, Ross A, et al. Systematic review and
meta-analysis of the effec-
tiveness of pharmacist-led medication reconciliation in the
community after hospital
discharge. BMJ Qual Saf. 2018;27:308–320.
https://doi.org/10.1136/bmjqs-2017-
007087.
16. Cheema E, Alhomoud FK, Kinsara ASAL-D, et al. The
impact of pharmacists-led
medicines reconciliation on healthcare outcomes in secondary
care: a systematic
review and meta-analysis of randomized controlled trials. PLoS
One. 2018;13.
https://doi.org/10.1371/journal.pone.0193510 e0193510.
17. Redmond P, Grimes TC, McDonnell R, Boland F, Hughes C,
Fahey T. Impact of
medication reconciliation for improving transitions of care.
Cochrane Database Syst

Rev. 2018;23:CD010791.
https://doi.org/10.1002/14651858.CD010791.pub2.
18. Koehler BE, Richter KM, Youngblood L, et al. Reduction of
30-day postdischarge
hospital readmission or emergency department (ED) visit rates
in high-risk elderly
medical patients through delivery of a targeted care bundle. J
Hosp Med.
2009;4:211–218. https://doi.org/10.1002/jhm.427.
19. Kripalani S, Roumie CL, Dalal AK, et al. PILL-CVD
(Pharmacist Intervention for Low
Literacy in Cardiovascular Disease) Study Group. Effect of a
pharmacist intervention
on clinically important medication errors after hospital
discharge: a randomized
trial. Ann Intern Med. 2012;157:1–10.
https://doi.org/10.7326/0003-4819-157-1-
201207030-00003.
20. Wolfe D, Yazdi F, Kanji S, et al. Incidence, causes, and
consequences of preventable
adverse drug reactions occurring in inpatients: a systematic
review of systematic
reviews. PLoS One. 2018;13.
https://doi.org/10.1371/journal.pone.0205426
e0205426.
21. Bayoumi I, Howard M, Holbrook AM, Schabort I.
Interventions to improve medica-
tion reconciliation in primary care. Ann Pharmacother.
2009;43:1667–1675. https://
doi.org/10.1345/aph.1M059.
22. Chhabra PT, Rattinger GB, Dutcher SK, Hare ME, Parsons

KL, Zuckerman IH.
Medication reconciliation during the transition to and from
long-term care settings: a
systematic review. Res Soc Adm Pharm. 2012;8:60–75.
https://doi.org/10.1016/j.
sapharm.2010.12.002.
23. Thompson CA. California pharmacists to ensure accuracy of
high-risk patients' ad-
mission medication lists. Am J Health Syst Pharm.
2018;75:1961–1963. https://doi.
org/10.2146/news180076.
24. Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive
pharmacist intervention
to reduce morbidity in patients 80 years or older: a randomized
controlled trial. Arch
Intern Med. 2009;169:894–900.
https://doi.org/10.1001/archinternmed.2009.71.
8
https://doi.org/10.1001/archinte.167.12.1305
https://doi.org/10.1111/ajag.12205
https://doi.org/10.1111/ajag.12205
https://doi.org/10.7326/0003-4819-150-3-200902030-00007
http://www.ihi.org/resources/Pages/Tools/MedicationReconcilia
tionReview.aspx
https://doi.org/10.1001/archinternmed.2012.2246
https://doi.org/10.7326/0003-4819-158-5-201303051-00006

https://doi.org/10.1136/bmjopen-2015-010003
https://doi.org/10.1136/bmjopen-2015-010003
https://doi.org/10.1186/1471-2288-11-15
http://www.training.cochrane.org/handbook
http://www.training.cochrane.org/handbook
http://refhub.elsevier.com/S1551-7411(19)30680-1/sref11
https://doi.org/10.1371/journal.pmed.1000097
https://doi.org/10.1371/journal.pmed.1000097
https://doi.org/10.1136/bmj.j4008
https://doi.org/10.1177/1060028014543485
https://doi.org/10.1136/bmjqs-2017-007087
https://doi.org/10.1136/bmjqs-2017-007087
https://doi.org/10.1002/14651858.CD010791.pub2
https://doi.org/10.1002/jhm.427
https://doi.org/10.7326/0003-4819-157-1-201207030-00003
https://doi.org/10.7326/0003-4819-157-1-201207030-00003
https://doi.org/10.1345/aph.1M059
https://doi.org/10.1345/aph.1M059
https://doi.org/10.2146/news180076
https://doi.org/10.2146/news180076
https://doi.org/10.1001/archinternmed.2009.71Impact of
medication reconciliation on health outcomes: An overview of
systematic reviewsIntroductionMethodsEligibility
criteriaInformation sourcesStudy selectionQuality
assessmentData collectionResultsQuality of the systematic
reviewsCharacteristics of included systematic reviews and meta-
analysesEffectiveness of medication reconciliation on health
outcomes (see Table 4)MortalityLength of stayEmergency
Department visitsUnplanned readmissionsPhysician

visitsHealthcare
utilizationDiscussionConclusionFundingmk:H1_21Acknowledge
mentsSupplementary dataReferences
NR449 Evidence Based Practice
Required Uniform Assignment: Analyzing Published Research
Purpose
The purpose of this paper is to interpret the two articles
identified as most important to the group topic.
COURSE OUTCOMES
This assignment enables the student to meet the following
course outcomes:
CO 2: Apply research principles to the interpretation of the
content of published research studies. (POs #4
and #8)
CO 4: Evaluate published nursing research for credibility and
clinical significance related to evidence- based
practice. (POs #4 and #8)
DUE DATE
Refer to the course calendar for due date information. The
college’s Late Assignment policy applies to this
activity.

TOTAL POINTS POSSIBLE: 200 POINTS REQUIREMENTS
The paper will include the following.
1. Clinical question
a. Description of problem
b. Significance of problem
c. Purpose of paper
2. Description of findings
a. Summarize basics in the Matrix Table as found in Assignment
Documents in e-College.
b. Describe
i. Concepts
ii. Methods used
iii. Participants
iv. Instruments including reliability and validity
v. Answer to “Purpose” question vi. Identify next step for group
3. Conclusion of paper
4. Format
a. Correct grammar and spelling
b. Use of headings for each section
c. Use of APA format (sixth edition)
d. Page length: three pages
PREPARING THE PAPER

1. Please make sure you do not duplicate articles within your
group.
2. Paper should include a title page and a reference page.
DIRECTIONS AND ASSIGNMENT CRITERIA
Assignment
Criteria
Points % Description
Clinical Question
30
15%
1. Problem is described: What is the focus of your group’s
work?
2. Significance of the problem is described: What health
outcomes result
from your problem? Or what statistics document this is a
problem? You
may find support on websites for government or professional
organizations.

3. Purpose of your paper: What will your paper do or describe?
“The purpose
of this paper is to . . .”
**Please note that although most of these questions are the
same as
you addressed in paper 1, the purpose of this paper is different.
You
can use your work from paper 1 for items 1 and 2 above,
including
any suggestions for improvement provided as feedback. Item 3
above
should be specific to this paper.
Description of
Findings: Summary
60
30%
Summarize the basics of each article in a matrix table that
appears in the
appendix.
Description of
Findings:
Description
60 30%
Describe in the body of the paper the following.

• What concepts have been studied?
• What methods have been used?
• Who are the participants or members of the samples?
• What instruments have been used? Did the authors describe
the
reliability and validity?
• How do you answer your original “purpose of this paper”
question?
Do the findings of the articles provide evidence for your
answers? If
so, how? If not, what is still needed to be able to answer your
question?
• What is needed for the next step? Identify two questions that
can
help guide the group’s work.
Description of
Findings: Conclusion 20 10%
Conclusion: Review major findings in your paper in a summary
paragraph.
Format 30
15%
1. Correct grammar and spelling

2. Use headings for each section: Problem, Synthesis of the
Literature
(Concepts, Methods, Participants, Instruments, Implications for
Future
Work), Conclusion.
3. APA format (sixth ed.): Appendices follow references.
4. Paper length: Three pages
Total 200 100%
NR449 RUA Analyzing Published Research .docx
Revised 07 / 25 /2016 2
NR449 RUA A nalyzing Published Research .docx
Revised 07/25 /2016 4
GRADING RUBRIC
Assignment
Criteria
Outstanding or Highest
Level of Performance
A (92–100%)

Very Good or High Level of
Performance
B (84–91%)
Competent or Satisfactory
Level of Performance
C (76–83%)
Poor, Failing or
Unsatisfactory Level of
Performance F
(0–75%)
Clinical Question
(30 points)
Includes all elements in a
manner that is clearly
understood.
• Problem description
provides focus of the
group’s work.
• Significance of the problem
is clearly stated and
supported by current
evidence.

• Purpose of paper is clearly
stated.
28-30 points
Missing only one element
OR
One element is not presented
clearly
• Problem description provides
focus of the group’s work.
• Significance of the problem is
clearly stated and supported
by current evidence.
stated.
26-27 points
Missing two elements
OR
One element is not presented
clearly

stated.
23-25 points
Missing two or more elements
AND/OR
One or more elements are not
presented clearly
stated.
0-22 points
Description of
Findings:
Summary
(60 points)

Summary omits no
more than one required
item from the Evidence
Matrix Table.
55-60 points
Summary omits two or three
required items from the
Evidence Matrix Table.
51-55 points
Summary omits four required
items from the Evidence
Matrix Table.
46-50
points
Summary omits five or more
required items from the
Evidence Matrix Table.
0–45

points
Revised 07/25 /2016 5
Description of
Findings:
Description
(60 points)
Description includes ALL
elements.
• What concepts have
been studied?
• What methods have
been used?
Description missing no more than
one element.
• What concepts have been
studied?

• What methods have been
used?
Description missing no more than
two elements.
studied?
used?
Description missing three or
more elements.
studied?
used?

Revised 07/25 /2016 6
• Who are the
participants or
members of the
samples?
• What instruments
have been used?
Did the authors
describe the
reliability and
validity?
• How do you answer
your original “the
purpose of this
paper” question?
Do the findings of
the articles provide
evidence for your
answers? If so,
how? If not, what is
still needed to be
able to answer your
question?
• What is needed for
the next step?
Identify two
questions that can
help guide the
group’s work.

56–60 points
• Who are the participants or
members of the samples?
• What instruments have
been used? Did the authors
describe the reliability and
validity?
• How do you answer your
original “the purpose of
this paper” question? Do
the findings of the articles
provide evidence for your
answers? If so, how? If not,
what is still needed to be
able to answer your
question?
• What is needed for the
next step? Identify two
questions that can help
guide the group’s work.
51–55 points
validity?

able to answer your
question?
46–50 points
validity?
able to answer your
question?

0–45 points
Revised 07/25 /2016 7
Description of
Findings:
Conclusion
(20 points)
Summary paragraph includes
ALL major findings from
article.
• Independently extracts
complex data from a
variety of quantitative
sources, presents those
data in summary form,

makes appropriate
Summary paragraph omits ONE
major finding from article.
• Independently extracts complex
data from a variety of
quantitative sources, presents
those data in summary form,
makes appropriate
connections and inferences
consistent with the data, and
Summary paragraph omits TWO
major findings from article.
makes appropriate
Summary paragraph omits THREE
or MORE major findings from
article.

makes appropriate
relates them to a larger
context.
• Recognizes points of view
and value assumptions in
formulating
interpretation of data
collected and articulates
the point of view in a
given situation.
• Identifies
misrepresentations in the
presentation points of
quantitative data and the
logical and empirical
fallacies in inferences
drawn from data.
19-20 points
relates them to a larger context.
• Recognizes points of view and
value assumptions in

formulating interpretation of
data collected and articulates
the point of view in a given
situation.
• Identifies misrepresentations in
the presentation of
logical and empirical fallacies in
inferences drawn from data.
17-18 points
relates them to a larger context.
situation.
the presentation of
logical and empirical fallacies in
inferences drawn from data.

16 points
relates them to a larger
context.
situation.
the presentation of quantitative
data and the logical and
empirical fallacies in inferences
drawn from data.
0-15 points

Revised 07/25 /2016 8
Grammar, Spelling,
Mechanics, and
APA Format
(30 points)
• Length is three full
pages.
• Used appropriate APA
format and is free of
errors.
• Includes ALL headings
and subheadings as
instructed.
• Grammar, spelling, and
mechanics are free of
errors.
28–30 points
• Length is no more than
one quarter page under or

over.
format, with one type of
error.
• Includes ALL headings and
subheadings as instructed.
mechanics have one type
of error.
26–27 points
• Length is no more than one
half page under or over.
format, with two types of
errors.
• Includes ALL headings and
subheadings as instructed.
mechanics have two types
of errors.
23–25 points

PICOTIn hospitalized medsurg patients , does med reconciliatio.docx

PICOTIn hospitalized medsurg patients , does med reconciliatio.docx

Recommended

Recommended

More Related Content

Similar to PICOTIn hospitalized medsurg patients , does med reconciliatio.docx

Similar to PICOTIn hospitalized medsurg patients , does med reconciliatio.docx (20)

More from stilliegeorgiana

More from stilliegeorgiana (20)

Recently uploaded

Recently uploaded (20)

PICOTIn hospitalized medsurg patients , does med reconciliatio.docx