***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND Previous studies found that medication errors result from lack of sufficient information during the prescribing step . Therefore , it is proposed that having a pharmacist available when patients are evaluated during the rounding process may reduce the likelihood of preventable adverse drug events ( ADEs ) . The objectives of this study were to evaluate the impact of having a pharmacist participate with a physician rounding team on preventable ADEs in general medicine units and to document pharmacist interventions made during the rounding process . METHODS A single-blind , st and ard care-controlled study design was used to compare  patients receiving care from a rounding team including a pharmacist with patients receiving st and ard care ( no pharmacist on rounding team ) . Patients admitted to and discharged from the same general medicine unit were included in the study . The main outcome measure of this study was preventable ADEs . Patient records were r and omly selected and evaluated by a blinded process involving independent senior pharmacist specialists and a senior staff physician . Interventions made by the pharmacists in the treatment group were documented . RESULTS The rate of preventable ADEs was reduced by 78 % , from 26.5 per 1000 hospital days to 5.7 per 1000 hospital days . There were 150 documented interventions recommended during the rounding process , 147 of which were accepted by the team . The most common interventions were ( 1 ) dosing-related changes and ( 2 ) recommendations to add a drug to therapy . CONCLUSION Pharmacist participation with the medical rounding team on a general medicine unit contributes to a significant reduction in preventable ADEs BACKGROUND There is evidence that pharmacist interventions improve clinical outcomes . The few studies that address economic outcomes ( a ) often report estimated instead of actual medical costs , ( b ) report only medication costs , or ( c ) have been conducted in setting s that are not typical of community-based primary care . OBJECTIVES To ( a ) determine whether a clinical pharmacist 's recommendations to physicians regarding optimizing medication therapy are related to medical costs in capitated patients in an internal medicine practice , and ( b ) compare what primary care physicians ( PCPs ) in a comparison group actually did proactively to optimize medication therapy versus what a clinical pharmacist would have recommended to them . METHODS This was a prospect i ve , controlled study comparing 2 internal medicine practice s. Study enrollment was performed using a screening process carried out every 1 - 2 weeks on a rolling basis for 1 year from July 2001 through June 2002 . Eligibility criteria for prospect i ve enrollment were ( a ) 1 or more risk factors : at least 1 chronic disease or an event ( e.g. , emergency room visit , adverse drug reaction , medication nonadherence ) or aged 50 years or older , ( b ) a scheduled visit to see a PCP within 2 weeks from the screening date or a diagnosis of diabetes without a PCP visit during the first 6 months of the study , ( c ) need for optimization of medication therapy as determined by a clinical pharmacist on the screening date , and ( d ) 12 months of continuous insurance eligibility before enrollment in the study . For inclusion in the final study analyses , patients were also required to have continuous insurance eligibility through 12 months from study enrollment . One clinical pharmacist made recommendations to optimize medication therapy in the intervention group . For the comparison group , the same pharmacist proposed recommendations that remained concealed from the physicians . The primary outcome measure was per patient per year ( PPPY ) medical cost , based on plan liability ( gross allowable costs minus patient costs ) , excluding prescription drug cost . Additional outcome measures included numbers of outpatient visits , hospital admissions , emergency room ( ER ) visits per 1,000 patients , and hospital days ; and percent of recommendations that were accepted by the PCPs . Changes in outcome measures from the pre-intervention to postintervention period were compared across study groups in a difference-indifference analysis , using the Student 's t-test for normally distributed data and the Mann-Whitney U-test ( nonparametric ) for skewed data . RESULTS There were 127 and 216 adult patients in the intervention and comparison groups , respectively . The primary outcome , change in mean PPPY medical ( excluding pharmacy ) cost , did not differ significantly between the groups ( P = 0.711 ) . The between-group difference in the change in ER visits per 1,000 patients approached statistical significance ( P = 0.054 ) . Intervention group patients were more likely than comparison group patients to have the following issues addressed : medication nonadherence ( 85.7 % vs. 40.0 % , respectively ; P = 0.032 ) , untreated indication ( 72.6 % vs. 11.5 % , P < 0.001 ) , suboptimal medication choice ( 60.0 % vs. 5.9 % , P < 0.001 ) and cost-ineffective drug therapies ( 72.1 % vs. 6.5 % , P < 0.001 ) . Of the estimated number of actionable opportunities identified for the comparison group ( but concealed from the physicians ) , 23.5 % were adopted by comparison group physicians without any assistance from a clinical pharmacist . CONCLUSION Compared with patients of PCPs who received no input from a clinical pharmacist  , patients of PCPs who received clinical pharmacist recommendations were more likely to have several medication-related issues addressed , including medication nonadherence , untreated indications , suboptimal medication choices , and cost-ineffective drug therapies . However , total medical ( excluding pharmacy ) costs for the intervention and comparison groups were not significantly different Background : Hospital discharge is an interlace of care when patients are at a high risk of medication discrepancies as they transition from hospital to home . These discrepancies are important , as they may contribute to drug-related problems , medication errors , and adverse drug events . Objective : To Identify , characterize , and assess the clinical impact of unintentional medication discrepancies at hospital discharge . Methods : All consecutive general internal medicine patients admitted for at least 72 hours to a tertiary care teaching hospital were prospect ively assessed . Patients were excluded if they were discharged with verbal prescriptions ; died during hospitalization ; or transferred from or to a nursing home , another institution , or another unit within the same hospital . The primary endpoint was to determine the number of patients with at least one unintended medication discrepancy on hospital discharge . Medication discrepancies were assessed through comparison of a best possible medication discharge list with the actual discharge prescriptions . Secondary objectives were to characterize and assess the potential clinical impact of the unintentional discrepancies . Results : From March 14,2006 , to June 2,2006,430 patients were screened for eligibility ; 150 patients were included in the study . Overall , 106 ( 70.7 % ) patients had at least one actual or potential unintentional discrepancy . Sixty-two patients ( 41.3 % ) had at least one actual unintentional medication discrepancy al hospital discharge and 83 patients ( 55.3 % ) had at least one potential unintentional discrepancy . The most common unintentional discrepancies were an incomplete prescription requiring clarification , which could result in a patient delay in obtaining medications ( 49.5 % ) , and the omission of medications ( 22.9 % ) . Of the 105 unintentional discrepancies , 31 ( 29.5 % ) had the potential to cause possible or probable patient discomfort and /or clinical deterioration . Conclusions : Medication discrepancies occur commonly on hospital discharge . Underst and ing the type and frequency of discrepancies can help clinicians better underst and ways to prevent them . Structured medication reconciliation may help to prevent discharge medication discrepancies Background : Medication errors at the time of hospital admission and discharge are common and can lead to preventable adverse drug events . The objective of this study was to describe the potential impact of a medication reconciliation process to identify and rectify medication errors at the time of hospital admission and discharge . Methods : Sixty r and omly selected patients were prospect ively enrolled at the time of admission to a Canadian community hospital . At admission , patients ’ medication orders were compared with pre-admission medication use based on medication vials and interviews with patients , caregivers , and /or outpatient healthcare providers . At discharge , pre-admission and in-patient medications were compared with discharge orders and written instructions . All variances were discussed with the prescribing physician and classified as intended or unintended ; unintended variances were considered to be medication errors . An internist classified the clinical importance of each unintended variance . Results : Overall , 60 % ( 95 % CI 48 to 72 ) of patients had at least one unintended variance and 18 % ( 95 % CI 9 to 28 ) had at least one clinical ly important unintended variance . None of the variances had been detected by usual clinical practice before reconciliation was conducted . Of the 20 clinical ly important variances , 75 % ( 95 % CI 56 to 94 ) were intercepted by medication reconciliation before patients were harmed . Discussion : Unintended medication variances at the time of hospital admission and discharge are common and clinical ly important . The medication reconciliation process identified and addressed most of these unintended variances before harm occurred . In this small study , medication reconciliation was a useful method for identifying and rectifying medication errors at times of transition . Reconciliation warrants broader evaluation BACKGROUND Prior studies suggest that unintended medication discrepancies that represent errors are common at the time of hospital admission . These errors are particularly worthy of attention because they are not likely to be detected by computerized physician order entry systems . METHODS We prospect ively studied patients reporting the use of at least 4 regular prescription medications who were admitted to general internal medicine clinical teaching units . The primary outcome was unintended discrepancies ( errors ) between the physicians ' admission medication orders and a comprehensive medication history obtained through interview . We also evaluated the potential seriousness of these discrepancies . All discrepancies were review ed with the medical team to determine if they were intentional or unintentional . All unintended discrepancies were rated for their potential to cause patient harm . RESULTS After screening 523 admissions , 151 patients were enrolled based on the inclusion criteria . Eighty-one patients ( 53.6 % ; 95 % confidence interval , 45.7%-61.6 % ) had at least 1 unintended discrepancy . The most common error ( 46.4 % ) was omission of a regularly used medication . Most ( 61.4 % ) of the discrepancies were judged to have no potential to cause serious harm . However , 38.6 % of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration . CONCLUSIONS Medication errors at the time of hospital admission are common , and some have the potential to cause harm . Better methods of ensuring an accurate medication history at the time of hospital admission are needed OBJECTIVES to investigate the effectiveness of a  pharmacy discharge plan  in elderly hospitalized patients . DESIGN r and omized controlled trial . SUBJECTS AND SETTING S we r and omized patients aged 75 years and older on four or more medicines who had been discharged from three acute general and one long-stay hospital to a pharmacy intervention or usual care . INTERVENTIONS the hospital pharmacist developed discharge plans which gave details of medication and support required by the patient . A copy was given to the patient and to all relevant professionals and carers . This was followed by a domiciliary assessment by a community pharmacist . In the control group , patients were discharged from hospital following st and ard procedures that included a discharge letter to the general practitioner listing current medications . OUTCOMES the primary outcome was re-admission to hospital within 6 months . Secondary outcomes included the number of deaths , attendance at hospital outpatient clinics and general practice and proportion of days in hospital over the follow-up period , together with patients ' general well-being , satisfaction with the service and knowledge of and adherence to prescribed medication . RESULTS we recruited 362 patients , of whom 181 were r and omized to each group . We collected hospital and general practice data on at least 91 and 72 % of patients respectively at each follow-up point and interviewed between 43 and 90 % of the study subjects . There were no significant differences between the groups in the proportion of patients re-admitted to hospital between baseline and 3 months or 3 and 6 months . There were no significant differences in any of the secondary outcomes . CONCLUSIONS we found no evidence to suggest that the co-ordinated hospital and community pharmacy care discharge plans in elderly patients in this study influence outcomes Introduction : Care home residents are at particular risk from medication errors , and our objective was to determine the prevalence and potential harm of prescribing , monitoring , dispensing and administration errors in UK care homes , and to identify their causes . Methods : A prospect i ve study of a r and om sample of residents within a purposive sample of homes in three areas . Errors were identified by patient interview , note review , observation of practice and examination of dispensed items . Causes were understood by observation and from theoretically framed interviews with home staff , doctors and pharmacists . Potential harm from errors was assessed by expert judgement . Results : The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines . One hundred and seventy-eight ( 69.5 % ) of residents had one or more errors . The mean number per resident was 1.9 errors . The mean potential harm from prescribing , monitoring , administration and dispensing errors was 2.6 , 3.7 , 2.1 and 2.0 ( 0 = no harm , 10 = death ) , respectively . Contrib 
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There is limited evidence of the potential of these discrepancies to cause harm .
The studies reported conflicting findings regarding the impact of medication review on length of stays , readmissions , and mortality .
Conclusions : The evidence demonstrates that medication reconciliation has the potential to identify many medication discrepancies and reduce potential harm , but the impact on clinical outcomes is less clear .
Similarly , medication review can detect medication-related problems in many patients , but evidence of clinical impact is scant .
Overall , there is limited evidence that medication reconciliation and medication review processes , as currently performed , significantly improve clinical outcomes , such as reductions in hospital readmissions