Jennifer Miao
PharmD Candidate 2014
Hanlin Li
PharmD Candidate 2014
Tran H. Tran, PharmD, BCPS
Assistant Clinical Professor
St. John’s University
Queens, New York
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In its 2011 National Patient Safety Goals, the Joint Commission states that health care providers need to “maintain and communicate accurate patient medication information.”1 Medication reconciliation can help ensure that the medications taken by a patient are accurately reflected in the medication list found in the patient’s electronic health record. Numerous studies demonstrate that pharmacists can play a critical role in identifying and reconciling medications to minimize discrepancies.2-6

We conducted a study to describe medication discrepancies that pharmacy students caught during phone calls to patients conducted within 72 hours of discharge from the hospitalist service at a large academic hospital. Patients discharged to nursing home, prisons, or shelters were excluded. We asked patients to describe the name, dose, and frequency of medications they were currently taking. Patients’ responses were compared with discharge medication lists from electronic health record (EHR) systems. Discrepancies were documented and discussed with the pharmacist and medical team to identify the cause(s) of the discrepancies. Dispensing pharmacy information was collected and updated in the patients’ charts to aid future communication between hospital staff and outpatient pharmacists.

The students called 71 patients discharged from the hospitalist service over 34 days. After making up to 3 attempts per patient (average 1.48), they reached 48 patients (67.6%). Of those reached, nearly 40% (n=21) had a drug discrepancy. The figure indicates the frequency with which each type of discrepancy occurred.

Overall, medication discrepancies occurred frequently following hospital discharge. The reasons for discrepancies varied greatly and were sometimes intentional. Post-discharge phone calls gave students the opportunity to reiterate the importance of medication adherence, clarify side effects, and relay patient-reported adverse effects back to the medical team. Students also confirmed clinic appointments and identified patients in need of additional counseling or follow-up. The students reported that they faced a few obstacles during some of the phone calls, such as language barriers, inconsistency of patient information in EHRs, and missing pharmacy information.

Figure. Medication discrepancies captured during post-discharge phone calls.

In future studies, initiating pharmacy student involvement early in the medication reconciliation process (ie, time of admission) should be considered. Earlier access to accurate patient information will streamline medication reconciliation and facilitate counseling during discharge. Our study found that pharmacy students can have a positive impact on patient care by performing post-discharge phone calls to detect medication discrepancies on an internal medicine service. Integrating pharmacy students in this process provides them with an opportunity to apply their skills and more actively participate in patient care.


  1. The Joint Commission. National patient safety goals effective July 1, 2011. Ambulatory Health Care Accreditation Program. NPSG.01.01.01.​assets/​1/​6/​NPSG_​EPs_​Scoring_​AHC_​20110707.pdf. Accessed January 13, 2014.
  2. Bedell SE, Jabbour S, Goldberg R, et al. Discrepancies in the use of medications: their extent and predictors in an outpatient practice. Arch Intern Med. 2000;160(14):2129-2134.
  3. 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(4):211-218.
  4. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
  5. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166(5):565-571.
  6. Wong JD, Bajcar JM. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42(10):1373-1379.

This research was presented at the 2013 annual meeting of the American College of Clinical Pharmacists (abstract 383).