Care Gaps in the Electronic Discharge Medication Reconciliation Process at an Acute Care Facility.

Background: Many patients experience adverse events at the time of discharge from hospital, and most of these events are medication-related. To improve patient safety, Health PEI (the health authority for Prince Edward Island) has made medication reconciliation a priority. The Queen Elizabeth Hospital in Charlottetown is one of the few Canadian hospitals with an electronic discharge process. A discharge report has been developed to provide pertinent information to patients at discharge, including a final medication list to be shared with the community pharmacy at the patient's discretion.

Objective: To identify care gaps related to the transfer of information for the medication reconciliation part of the electronic discharge process at the Queen Elizabeth Hospital.

Methods: The study was conducted on 4 nursing units offering medical and surgical services. Data for the 8-week prospective study (June to August 2016) were collected using a study-specific discharge evaluation checklist and hospital-to-community pharmacy feedback form. All inpatients 65 years of age or older with a hospital stay longer than 4 days who were receiving more than 5 medications on discharge were eligible to participate.

Results: During the study period, data were compiled for the 72 of 154 eligible patients who provided consent. Of these, 69 (96%) had a change in medications. Follow-up showed that 12 (17%) of the 72 discharge reports had reached the patient's community pharmacy; of these, 5 had been sent from a community care or long-term care facility. Fifty-four patients were discharged home, of whom 50 presented to the community pharmacy after discharge, 37 (74%) of these on the day of discharge.

Conclusions: Most community pharmacies did not receive a discharge report from the patient or from the patient's community care or long-term care facility. This represented the largest care gap in the electronic discharge medication reconciliation process at the study hospital.