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Necessity of Transition of Care Pharmaceutical Service Based on the Effectiveness of Discharge Medication Reconciliation
J. Kor. Soc. Health-syst. Pharm. 2021;38:306-318
Published online August 31, 2021;
© 2021 Korean Society of Health-System Pharmacists

Jaeeun Han*, Hyeryun Jung*, Saetbyeol Kim, Joohee Oh, Myoungon Eun and Younghee Lee

Department of Pharmacy, Ajou University Hospital 164, Worldcup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
Correspondence to: 이영희 Tel:031-219-5686
*한재은과 정혜련은 공동 제1저자로서 본 논문에 동등하게 기여함
Received June 2, 2021; Revised June 23, 2021; Accepted July 1, 2021.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background : Since September 2020, we have expanded the task of performing reconciliation of discharge medications. The purpose of this study was to identify the role of pharmacists in discharge through medication reconciliation.
Methods : This study compared pharmacists’ interventions regarding discharge patients September 1, 2019 to February 29, 2020 (pre-DMR) and September 1, 2020 to February 28, 2021 (post-DMR). The criteria of the Pharmaceutical Care Network Europe (PCNE) version 9.0 were used to determine the types and causes of drug-related problems (DRPs). Factors adopted for intervention were analyzed. The Eadon grade was applied to assess the significance of interventions. The difference of emergency department (ED) visits within 30 days of discharge with or without an intervention was analyzed.
Results : Pre-DMR 607 cases and post-DMR 902 cases of interventions were analyzed. The distribution of type and cause of DRPs was changed between the two periods (p<0.01). Treatment safety (type) and medication selection (cause) in post-DMR increased. The factors adopted for intervention, patients’ history such as clinical progression or self-medication were considered more in post-DMR (pre-DMR vs. post-DMR, 14.6% vs. 34.1%). The clinical significance of intervention increased in post-DMR (p<0.01). Our data did not show significant differences in ED visits within 30 days of discharge. Only post-DMR period cases were enrolled to ED visit analysis. Intervention cases were not superior compared with others, but a high risk group with potential ED visit needed reconciliation the most (odds ratio 23.69, 95% confidence interval 15.53-36.15).
Conclusion : We confirmed that reconciliation of discharge medication is an essential process for treatment safety. Through this process, medication review and monitoring closely by pharmacists based on patient’s history are possible. A pharmacist’s role is needed to prevent medication discrepancies at the transition of care, such as medication reconciliation.
Keywords : Transition of care, Medication reconciliation, Discharge medication, Drug related problem

August 2021, 38 (3)