Clinical pharmacy + medication reconciliation

Clinical pharmacy

focuses on patient-centered pharmaceutical care to optimize therapeutic outcomes, minimize medication errors, and promote cost-effective therapy.

Medication Reconciliation (Med Rec)

is a core clinical process performed at all transitions of care to ensure seamless, accurate drug therapy and prevent adverse drug events (ADEs)

Pharmaceutical Care

is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life.

Unnecessary Drug Therapy

Patient takes a medication without a current clinical indication.

Needs Additional Drug Therapy

Untreated medical condition requiring new drug therapy.

Ineffective Drug

Patient is taking a drug that is not effective for their condition.

Dosage Too Low

Subtherapeutic dose or improper dosing frequency/duration

Dosage Too High

Supratherapeutic dose leading to toxicity

Adverse Drug Reaction (ADR)

Undesirable response caused by the drug.

Drug Interaction

Drug-drug, drug-food, or drug-lab interactions altering efficacy or safety.

Non-Adherence

Patient does not or cannot take the medication correctly.

Transitions of Care (The 3 Critical Checkpoints)

Admission

Intra-facility Transfer

Discharge

Admission

Comparing pre-admission home medications with initial hospital admission orders.

Intra-facility Transfer

Comparing current orders with new orders when moving between levels of care (e.g., ICU to medical ward).

Discharge

Comparing hospital discharge orders with pre-admission home medications and inpatient therapy to produce the final discharge regimen.

Develop the Best Possible Medication History (BPMH)

Obtain a complete history using at least two independent sources (e.g., patient/caregiver interview, pill bottles, community pharmacy records, previous EHR).

Develop the List of Prescribed Medications

Gather the newly ordered inpatient or discharge medications.

Compare (Reconcile)

Systematically compare the BPMH against the new orders.

Make Clinical Decisions & Resolve Discrepancies

Identify and clarify any unexplained variances with the prescriber.

Communicate & Document

Provide the updated, finalized list to the patient, caregiver, and next healthcare provider.

Categorizing Medication Discrepancies

Intentional Discrepancy

Unintentional Discrepancy

Intentional Discrepancy

The prescriber deliberately changed, added, or held a drug based on clinical judgment (e.g., holding Lisinopril due to acute kidney injury).

• Documented: Reason is written in the chart.

• Undocumented: Prescriber intended the change, but forgot to document the rationale

Unintentional Discrepancy

An inadvertent mistake or breakdown in communication (e.g., accidentally omitting an outpatient anti-epileptic drug upon hospital admission). This is a medication error.

S – Subjective

Content & Sources: Information reported by the patient or caregiver that cannot be directly measured.

High-Yield PHLE Pearls: Chief Complaint (CC), History of Present Illness (HPI), self-reported allergies, reported adherence, social history.

O – Objective

Content & Sources: Measurable, verifiable clinical data obtained from physical exams or laboratory tests.

High-Yield PHLE Pearls: Vital signs (BP, HR, Temp), lab values (CrCl, electrolytes, CBC), diagnostic imaging, serum drug concentrations

A – Assessment

Content & Sources: The clinical evaluation and diagnosis of the patient's drug-related problems by the pharmacist

High-Yield PHLE Pearls: Differential diagnosis of MRPs, drug suitability, control status of disease states (e.g., "Uncontrolled T2DM secondary to non-adherence").

P – Plan

Content & Sources: Specific actionable interventions and monitoring parameters.

High-Yield PHLE Pearls: Drug changes (drug, dose, route, frequency), therapeutic monitoring parameters, safety parameters, patient counseling, follow-up timing.