***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: OBJECTIVES To study the feasibility and effectiveness of a  discharge planning intervention . DESIGN Quasi-experimental pre-post study design . SETTING General medicine wards at three hospitals : an academic medical center , a community teaching hospital , and a community-based nonteaching hospital . PARTICIPANTS All patients aged 65 and older admitted to the hospitalist services . INTERVENTION The intervention toolkit had five core elements : admission form with geriatric cues , facsimile to the primary care provider , interdisciplinary worksheet to identify barriers to discharge , pharmacist-physician collaborative medication reconciliation , and predischarge planning appointments . MEASUREMENTS Thirty-day readmission and return to emergency department rates and patient satisfaction with discharge . Odds ratios were determined , and site effects were examined accordig to interaction terms and Breslow Day statistics . RESULTS Two hundred thirty-seven patients were followed during the preintervention period , and 185 were exposed to the intervention . Patients characteristics were similar across the two time periods . The proportion of patients with high- quality transitions home , measured according to Coleman 's Care Transition Measures , increased from 68 % to 89 % ( odds ratio (OR)=3.49 , 95 % confidence interval (CI)=2.06 - 5.92 ) . Return to the emergency department within 3 days of discharge was lower in the intervention period ( 10 % vs 3 % , OR=0.25 , 95 % CI=0.10 - 0.62 ) . At 30 days , there was a lower rate of readmission ( 22 % vs 14 % , OR=0.59 , 95 % CI=0.34 - 0.97 ) and fewer visits to the emergency department ( 21 % vs 14 % , OR=0.61 , 95 % CI=0.36 - 1.03 ) ( P=.06 ) . CONCLUSION When hospitalized elderly patients are treated with consideration of their specific needs , healthcare outcomes can be improved Objective Heart failure patients are regularly admitted to hospital and frequently use multiple medication . Besides intentional changes in pharmacotherapy , unintentional changes may occur during hospitalisation . The aim of this study was to investigate the effect of a clinical pharmacist discharge service on medication discrepancies and prescription errors in patients with heart failure . Setting A general teaching hospital in Tilburg , the Netherl and s. Method An open r and omized intervention study was performed comparing an intervention group , with a  control group receiving regular care by doctors and nurses .  The clinical pharmacist discharge service consisted of review of discharge medication , communicating prescribing errors with the cardiologist , giving patients information , preparation of a written overview of the discharge medication and communication to both the community pharmacist and the general practitioner about this medication . Within 6 weeks after discharge all patients were routinely scheduled to visit the outpatient clinic and medication discrepancies were measured . Main outcome measure The primary endpoint was the frequency of prescription errors in the discharge medication and medication discrepancies after discharge combined . Results Forty-four patients were included in the control group and 41 in the intervention group . Sixty-eight percent of patients in the control group had at least one discrepancy or prescription error against 39 % in the intervention group ( RR 0.57 ( 95 % CI 0.37–0.88 ) ) . The percentage of medications with a discrepancy or prescription error in the control group was 14.6 % and in the intervention group it was 6.1 % ( RR 0.42 ( 95 % CI 0.27–0.66 ) ) . Conclusion This clinical pharmacist discharge service significantly reduces the risk of discrepancies and prescription errors in medication of patients with heart failure in the 1st month after discharge 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 BACKGROUND Clinical ly 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 clinical ly important medication errors after hospital discharge . DESIGN R and omized , controlled trial with concealed allocation and blinded outcome assessors . ( Clinical Trials.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 clinical ly 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 clinical ly 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 clinical ly 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 Clinical ly important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive , pharmacist-delivered intervention . PRIMARY FUNDING SOURCE National Heart , Lung , and Blood Institute Background : Internal hospital transfer is a vulnerable time during which patients are at high risk of medication discrepancies that can result in clinical ly significant harm , medication errors , and adverse drug events . Objective : To identify , characterize , and assess the clinical impact of unintentional medication discrepancies during internal hospital transfer and to investigate the influence of computerized prescriber order entry ( CPOE ) on medication discrepancies . Methods : All patients transferred between 10 inpatient units at 2 tertiary care hospitals were prospect ively assessed to identify discrepancies . Interfaces included transfers between ( 1 ) units that both used paper-based medication ordering systems ; ( 2 ) units that both used CPOE-based systems ; and ( 3 ) units that used both paper-based and CPOE-based systems ( hybrid transfer ) . The primary endpoint was the number of patients with at least 1 unintentional medication discrepancy during internal hospital transfer . Discrepancies were identified through assessment and comparison of a best possible medication transfer list with the actual transfer orders . A multidisciplinary team of clinicians assessed the potential clinical impact and severity of unintentional discrepancies . Results : Overall , 190 patients were screened and 129 patients were included . Eighty patients ( 62.0 % ) had at least 1 unintentional medication discrepancy at the time of transfer , and the most common discrepancy was medication omission ( 55.6 % ) . Factors that independently increased the risk of a patient experiencing at least 1 unintentional discrepancy included lack of best possible medication history , increasing number of home medications , and increasing number of transfer medications . Forty-seven patients ( 36.4 % ) had at least 1 unintentional discrepancy with the potential to cause discomfort and /or clinical deterioration . The risk of discrepancies was present regardless of the medication-ordering system ( paper , CPOE , or hybrid ) . Conclusions : Clinical ly significant medication discrepancies occur commonly during internal hospital transfer . A structured , collaborative , and clearly defined medication reconciliation process is needed to prevent internal transfer discrepancies and patient harm Background Medication reconciliation has been m and ated by the Irish government at transfer of care . Research is needed to determine the contribution of clinical pharmacists to the process . Objective To describe the contribution of emergency department based clinical pharmacists to admission medication reconciliation in Irel and . Main Outcome Measure Frequency of clinical pharmacist ’s activities . Setting Two public university teaching hospitals . Methodology Adults admitted via the accident and emergency department , from a non-acute setting , reporting the use of at least three regular prescription medications , were eligible for inclusion . Medication reconciliation was provided by clinical pharmacists to r and omly-selected patients within 24-hours of admission . This process includes collecting a gold-st and ard pre-admission medication list , checking this against the admission prescription and communicating any changes . A discrepancy was defined as any difference between the gold-st and ard pre-admission medication list and the admission prescription . Discrepancies were communicated to the clinician in the patient ’s healthcare record . Potentially harmful discrepancies were also communicated verbally . Pharmacist activities and unintentional discrepancies , both resolved and unresolved at 48-hours were measured . Unresolved discrepancies were confirmed verbally by the team as intentional or unintentional . A reliable and vali date d tool was used to assess clinical significance by medical consultants , clinical pharmacists , community pharmacists and general practitioners . Results In total , 134 patients , involving 1,556 medications , were included in the survey . Over 97 % of patients ( involving 59 % of medications ) experienced a medication change on admission . Over 90 % of patients ( involving 29 % of medications ) warranted clinical pharmacy input to determine whether such changes were intentional or unintentional . There were 447 interventions by the clinical pharmacist regarding apparently unintentional discrepancies , a mean of 3.3 per patient . In total , 227 ( 50 % ) interventions were accepted and discrepancies resolved . At 48-hours under half ( 46 % ) of patients remained affected by an unintentional unresolved discrepancy ( 60 % related to omissions ) . Verbally communicated discrepancies were more likely to be resolved than those not communicated verbally ( Chi-square ( 1 ) = 30.029 p < 0.05 ) . Under half of unintentional unresolved discrepancies ( 46 % ) had the potential to cause minor harm compared to 70 % of the resolved unintentional discrepancies . None had the potential to result in severe harm . Conclusion Clinical pharmacists contribute positively to admission medication reconciliation and should be engaged to deliver this service in Irel and Objective : This study aim ed to evaluate the use of a shared electronic primary health care record ( EHR ) to assist with medicines reconciliation in the hospital from admission to discharge . Methods : This is a prospect i ve cross-sectional , comparison evaluation for 2 phases , in a short-term elderly admissions ward in the United Kingdom . In phase 1 , full reconciliation of the medication history was attempted , using conventional methods , before accessing the EHR , and then the EHR was used to verify the reconciliation . In phase 2 , the EHR was the initial method of retrieving the medication history-vali date d by conventional methods . Results : Where reconciliation was led by conventional methods , and before any access to the EHR was attempted , 28 ( 28 % ) of hospital prescriptions were found to contain errors . Of 99 prescriptions subsequently checked using the EHR , only 50 ( 50 % ) matched the EHR . Of the remainder , 25 % of prescriptions contained errors when verified by the EHR . However , 26 % of patients had an incorrect list of current medications on the EHR . Using the EHR as the primary method of reconciliation , 33 ( 32 % ) of 102 prescriptions matched the EHR . Of those that did not match , 39 ( 38 % ) of prescriptions 
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However , there was no significant reduction in either the proportion of patients with medication discrepancies or the mean number of discrepancies per patient .
Conclusion Medication reconciliation supported by an electronic tool was able to minimize the incidence of medications with unintended discrepancy , mainly drug omissions .