A quasi-experimental study

Background Medication reconciliation can reduce errors, particularly among elderly and polymedicated patients. The inclusion of pharmacists obtaining the best possible medication history can further improve the identification and resolution of discrepancies. Aim To compare a structured pharmacist-led medication reconciliation program with usual care on detecting and resolving discrepancies during hospital admission for major orthopaedic surgeries. Methods Quasi-experimental study, conducted in a Portuguese tertiary hospital, involving adult patients undergoing major orthopaedic surgery and taking chronic medication. In Phase One (usual care), reconciliation lacked standardization; pharmacists performed it alongside other tasks, relying solely on medical records and reported unintentional discrepancies electronically to prescribers. In Phase Two (pharmacist-led medication reconciliation), a designated pharmacist obtained the best possible medication history, identified discrepancies and communicated them directly to clinical pharmacologists. Validated high-risk criteria were used to assess clinical significance. Primary outcomes were identifying, classifying, and resolving unintentional discrepancies across both phases. Results The study included 182 patients (91 in each phase). In Phase One, 212 discrepancies were identified, 91 were unintentional, of which 30 had clinical significance. Ten pharmacist interventions were performed, with 50 % acceptance rate. In Phase Two, 339 discrepancies were identified, 129 were unintentional, of which 46 had clinical significance. A total of 104 pharmacist interventions were performed, with 73 % acceptance rate. Identification and resolution of unintentional discrepancies significantly increased ( p < 0.001). Conclusion Pharmacist-led medication reconciliation, focusing on the best possible medication history collection and direct contact with physicians, significantly increased the identification and resolution of discrepancies, underlining its role in enhancing patient safety.