Construction,Intervention And Implementation Evaluation Of Medication Reconciliation Work Mode Led By Clinical Pharmacists

[Purpose]This study constructed a clinical pharmacist-led mode of medication reconciliation,carried out intervention tests and process evaluation,and provided a high-level evidence-based basis for filling the deficiency of the implementation mode and tools of medication reconciliation and promoting the standardization and routine of medication reconciliation.[Methods](1)The Delphi expert consultation was used to define the terminology and concepts related to medication reconciliation and to develop the Chinese medication discrepancy taxonomy(C-Med Tax).The virtual cases were used to test the reliability of C-Med Tax,and multifree margin Kappa was used to test the consistency between appraisers.(2)The literature and the focus group discussion were used to construct a medication reconciliation work model led by clinical pharmacists.A parallel randomized controlled trial(RCT)was carried out in a teaching tertiary hospital to evaluate the effect of medication reconciliation work model.(3)A questionnaire survey,in-depth interviews and subject analysis were used to identify the factors that promote and hinder the implementation of medication reconciliation.[Results](1)Through two rounds of expert consultation,this study defined the concepts of medication reconciliation,transition of care,best possible medication history,medication discrepancy,unintentional medication discrepancy,and intentional medication discrepancy.The clarity and comprehensiveness of these concepts of the content effectiveness scores were all between 0.91 and 1.00.This study constructed a C-Med Tax,which contained 2 first-level indicators of drug mismatch and drug partial matching,11 second-level indicators and23 third-level indicators.The content validity score of each indicator was above 0.8.After the reliability test of the virtual case,the overall consistency score was 0.76.(2)Based on the normalization process theory and improved model,this study constructed a medication reconciliation work model that included medication review,medication consultation,and patient education.This model was led by clinical pharmacists and cooperated with doctors and nurses,focused on identifying the medication discrepancies between best possible medication history(BPMH)and the physician admission medication orders(AMO)and evaluating the drug-related problems(DRPs)in the two lists.The effect of the process indicators of medication reconciliation intervention showed the following:(1)Clinical pharmacists proposed 245 intervention measures,and 92.65%were accepted and fully implemented.(2)The incidence of DRPs in the BPMH was 31.82%,and the incidence of DRPs in the AMO in the intervention group was 9.67%,which was significantly lower than before admission(χ~2=6.12,P<0.05).(3)The incidence of medication discrepancies in AMO was 95.76%,of which the unintentional discrepancies were 51.52%.According to C-Med Tax,90.45%of the unintentional discrepancies were omission drugs.(4)After the intervention of clinical pharmacists,the incidence of unintentional discrepancies showed a downwards trend with the passage of time(Z=-2.25,P=0.02).The outcome indicators showed that after medication reconciliation intervention,the medication compliance of the intervention group patients was significantly higher than that at admission(χ~2=4.91,P=0.03).However,there was no significant difference between the two groups of patients in the unplanned readmission rate within 30 days after discharge,length of stay or hospitalization expenses(P>0.05).The influencing factors of medication errors in BPMH were the number of medications taken by the patient(P=0.00)and the department where the patient was treated(P=0.03).(3)The promoting factors of the implementation of medication reconciliation were the consistent understanding and willingness to participate actively in medication reconciliation of clinical pharmacists and doctors.The obstacles were limited human resources,heavy workload,and lack of adequate training.[Conclusions]The C-Med Tax developed in this research has good validity and reliability.Medication reconciliation led by clinical pharmacists can effectively prevent and solve medication errors and improve patient medication compliance,but it has limited effects in reducing the use of medical resources.[Innovation and Deficiency](1)The C-Med Tax developed in this study had good consistency and applicability,which filled the shortage of relevant tools in the implementation of medication reconciliation in China.(2)The medication reconciliation work model constructed in this study emphasized the comprehensiveness of pharmacy service,the objectivity of process measurement,and the directness of the results.RCT verified that this model could reduce medication errors and improve patient medication compliance.This study enriched the content of the practice mode of medication reconciliation and promoted the development of implementation science.(3)This was the first study to use a combination of qualitative and quantitative methods based on normalization process theory to identify the factors promoting and hindering the implementation of medication reconciliation,and provided new ideas for the further optimization of medication reconciliation.The deficiency of this study:The sample hospital implemented in this study is a tertiary general teaching hospital in the western region.The extrapolation of some results requirs further study.Due to time constraints and complicated process changes,medication reconciliation was not implemented at discharge.