Medication Reconciliation: A Step Towards Patient Safety – An Interventional Approach in Geriatrics

Objective: To evaluate the effect of pharmacist-led medication reconciliation in geriatrics.Material and Methods: A prospective interventional study was conducted in the inpatient units of KIMS Al-Shifa Hospital from June 2022 to June 2023. The study focused on geriatric patients admitted to the General Medicine, Pulmonology, Gastroenterology, and Nephrology departments. Patient demographics and medication histories were collected at various stages of hospitalization. A standardized questionnaire was used to assess the knowledge and perceptions of healthcare professionals regarding pharmacist-led medication reconciliation.Results: A total of 73 healthcare professionals participated, including 31 pharmacists (43.0%), 30 nurses (41.0%), and 12 physicians (16.0%). Among the 165 patients studied, 1,697 medication discrepancies were identified, of which 95.0% (n=1,611) were intentional and 5.0% (n=86) were unintentional. The most common overall discrepancy was the addition of an order (56.0%), followed by the omission of an order (31.0%). Among unintentional discrepancies, the omission of an order was the most frequent (55.0%), especially during admission (46.0%). On average, each prescription contained four discrepancies. Pharmacists performed 86 interventions, and 66.0% were accepted by physicians (p-value<0.001). Discrepancies most often involved antimicrobials (25.0%) and drugs for acid-related disorders (11.0%).Conclusion: Unintentional discrepancies, particularly omissions, were the most frequent errors during admission. Pharmacist-led medication reconciliation significantly reduced medication discrepancies, highlighting the importance of pharmacist involvement in improving medication safety among geriatric patients.