Improving the discharge medication reconciliation process for an inpatient hematologic malignancies service by utilizing a pharmacist-facilitated workflow

Background: There is an opportunity for pharmacists to play a greater role during discharge medication reconciliation (MR), particularly in the oncology setting. Objectives: This initiative aims to decrease the number of medication discrepancies that occur during discharge MR and improve physician satisfaction with the discharge MR process for patients discharged from an inpatient adult hematologic malignancies (HM) service. Practice description: Patients on the HM service at Sibley Memorial Hospital, a community hospital located in Washington, DC, are co-managed by hospitalists and HM oncologists. The care team for the service also includes nursing staff and a clinical pharmacist. Practice innovation: The HM service piloted a pharmacist-facilitated workflow that involved the clinical pharmacist reconciling inpatient and outpatient medications prior to discharge, reviewing the discharge MR with the HM oncologist, and pending the discharge MR in the electronic medical record for the discharging hospitalist to review and sign. Evaluation methods: Prior to pilot implementation, discharge MRs of patients discharged from the HM service from November 2021 to December 2021 were analyzed by a pharmacist to identify medication discrepancies through retrospective chart review. This process was repeated to analyze pharmacist-facilitated discharge MRs for discrepancies for patients discharged between December 2021 to April 2022. Physician satisfaction with the process was assessed via survey pre and post-pilot. Results: A total of 30 and 37 discharge MRs were analyzed pre- and post-pilot, respectively. There were 19 medications discrepancies identified in the pre-pilot group and 6 discrepancies noted in the post-pilot group (P=0.038). Median physician satisfaction with the process was found to be 3.3 pre-pilot, and 5 post-pilot (on a scale of 1-5, with 5 being very satisfied). Conclusion: A pharmacist-facilitated workflow for discharge MR increased the accuracy of the discharge MR for patients on the HM service and improved physician satisfaction with the discharge MR process.