Canadian Pharmacists Journal - May/June 2019 - 177

836136
research-article2019

CPHXXX10.1177/1715163519836136C P J / R P CC P J / R P C

Practice Brief

PeeR-ReViewed

Practice Brief * Peer-reviewed

The pharmacist's role in successful
deprescribing through hospital
medication reconciliation
Ali Elbeddini, BScPharm, PharmD; Cathy X. Y. Zhang, PharmD
Medication reconciliation is the process of
ensuring that the patient's current medication list
is accurate and complete during transition of care.1
Many of the adverse effects caused by medication
discrepancies are preventable.2,3 As medication
reconciliation is done to prevent errors in omission, duplications, dosing or drug interactions,1 it
is an important means of patient harm reduction.4
Deprescribing is the planned and supervised process of dose reduction or discontinuation of medication(s) that may cause harm or
are no longer providing benefit.5 An accurate
and complete medication list is necessary for an
informed deprescribing care plan that accounts
for all problematic medications and medication
interactions.6 Moreover, medication reconciliation explores the patient's adherence, which is
essential when considering the efficacy and
safety of the patient's medications.7
Medication reconciliation in deprescribing
goes beyond attaining medication information
from a single source. On hospital admission,
the hospital pharmacist, pharmacy technician
or nurse obtains a complete list of the patient's
medication (including over-the-counter medications and natural health products) from community pharmacy/pharmacies, the patient,
caregiver and the family physician. On hospital
internal transfer or discharge, the hospital pharmacist disseminates the updated medication list
to all members within the patient's circle of care.
Pharmacists should play an active role in discharge medication reconciliation, especially in
patients with multiple medication adjustments
and health care providers. During the inpatient
hospital stay, the pharmacist is aware of the
patient's clinical progression and designs and
implements a deprescribing care plan accordingly. With extensive insight into the patient's
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clinical background, hospital pharmacists should
champion the safe transition of medication therapy from the hospital back to the community.
Winchester District Memorial Hospital
(WDMH) provides an inpatient rehabilitation
service. Deprescribing in this unit facilitates
monitoring and adjustment of care plans to
address the return of symptoms, withdrawals
and pharmacokinetic and pharmacodynamic
changes. Eleven patients were enrolled in the
deprescribing pilot program following discharge
from rehabilitation. We compared hospital
admissions 6 months prior to the deprescribing
intervention and admissions 6 months after the
deprescribing intervention. In this study, hospital
readmission went from 10 visits (prior to intervention) to 2 visits after intervention. Out of 56
deprescribed medications, 44 were eliminated, 12
were dose reduced and 9 were switched to a safer
alternative. Postdischarge deprescription reversal
occurred in only 5 out of 56 deprescribed medications. Anecdotally, other positive outcomes
included improved cognitive function, higher
alertness and reduced confusion. Most patients
exhibited improved physical stability and independence, and many demonstrated a reduction
in anticholinergic side effects such as dry mouth
and constipation. Successful dose reduction or
cessation of opioids led to reports of improved
bowel function among several patients. Also,
several patients experienced improvements in
hypotensive episodes after deprescribing.
The success of this deprescribing study was due
in part to careful medication reconciliation during hospital admission and discharge. Medication
reconciliation involves informing all members of
the patient's circle of care of medication changes,
thereby ensuring continuity of care. Communication to all parties enhances the quality of care as

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Canadian Pharmacists Journal - May/June 2019

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