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Author Notes:

Sunil Kripalani, MD, MSc, 1215 21st Ave S, Suite 6000 Medical Center East, Nashville, TN 37232, phone: 615-936-3525, fax: 615-936-1269, sunil.kripalani@vanderbilt.edu.

Dr. Kripalani is a consultant to and holds equity in PictureRx, LLC, which makes patient education tools to improve medication management.

PictureRx did not provide materials or funding for this study.

Dr. Schnipper is a consultant to QuantiaMD, for whom he has helped create on-line educational materials for both providers and patients regarding patient safety, including medication safety.

The findings of this study are not a part of those materials.

Dr. Schnipper has received grant funding from Sanofi Aventis for an investigator-initiated study to design and evaluate an intensive discharge and follow-up intervention in patients with diabetes.

The funder has had no role in the design of the study.


Research Funding:

Funded by R01 HL089755 (NHLBI, Kripalani) and in part by K23 HL077597 (NHLBI, Kripalani), K08 HL072806 (NHLBI, Schnipper), VA Career Development Award 04-342-2 (Roumie), and UL1 RR024975 (NCRR, Bernard).


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Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge: A Randomized Controlled Trial

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Journal Title:

Annals of Internal Medicine


Volume 157, Number 1


, Pages 1-U35

Type of Work:

Article | Post-print: After Peer Review


Background: Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs). Objective: To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge. Design: Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021) Setting: Two tertiary care academic hospitals. Patients: Adults hospitalized with acute coronary syndromes or acute decompensated heart failure. Intervention: Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. Measurements: The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs. Results: Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39] ). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]). Limitation: The characteristics of the study hospitals and participants may limit generalizability. Conclusion: Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacistdelivered intervention. Primary Funding Source: National Heart, Lung, and Blood Institute.

Copyright information:

© 2012 American College of Physicians.

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