2026 Southeastern Residency Conference

Title: Evaluation of the Medication Discrepancy Rate at Discharge
Purpose: Medication errors during hospital admissions have unfortunately followed patients out of the hospital. Many hospitals aim to resume accurate home medications within 24 hours of admission. However, medication discrepancies at the point of hospital discharge can be overlooked. The prevention of unnecessary or potentially harmful medications at discharge could reduce medication errors as well as provide a potential cost-savings opportunity for the health system. The purpose of this study is to evaluate the rate of medication discrepancies at hospital discharge by comparing prior-to-admission medication lists to discharge medication orders.
Methods: This study is an institutional review board approved, retrospective chart review. Patients discharged from Mobile Infirmary Medical Center between June 1st, 2025 to August 31st, 2025 will be randomized and evaluated by a manual chart review. Medication discrepancies are defined as intentional or unintentional differences between medication lists.  Patients will be excluded if they did not have a home medication list marked as “complete” during the admission, left the hospital admission against medical advice or had more than 2 readmissions during the study period. The primary outcome of this study is to identify the rate of medication discrepancies per medication in patients with a completed prior to admission list. Our secondary outcomes include 30-day readmission rates, types of medication discrepancies, and most common drug classes associated with errors. A subgroup analysis will be completed on patients with at least one unintentional discrepancy, focusing on average number of discrepancies per patient, average length of stay, and average number of home medications. Data that will be collected includes: patient demographics and types of medication discrepancies at the time of hospital discharge.
Results: A chart review was conducted on 350 patients. 137 were excluded, and our final included population was 213. Of the excluded patients, 77 had incomplete prior-to-admission (PTA) lists, 25 did not have any home medications on admission, 24 did not have a discharge medication reconciliation completed, and 11 were readmitted more than twice at the time of review. Baseline characteristics included a mean age of 67 + 14.5, 46% of our population were male, the mean length of stay was 14.3 [5] days, and the mean number of home medications was 6.3 + 4.2. The rate of unintentional medication discrepancies per medication was 6.6%. 87 out of 1345 medications screened had an unintentional discrepancy. The most common type of discrepancy was omission, which accounted for 54% of unintentional discrepancies. Dose was next at 16%, followed by frequency at 13%, other reasons at 9%, duplication at 5%, and route at 3%. Of our total population, 14% were readmitted within 30 days, and 21% of those readmitted had unintentional discrepancies. The top five most common drug classes were analgesics, insulin, statins, beta-blockers, and anticoagulants. 54 (25%) patients from our population had at least one unintentional discrepancy. We found that 85% of these patients had 1-2 discrepancies, 11% had 3-4 discrepancies, and 4% had 5-6 discrepancies. The mean number of discrepancies per patient was 1.6 + 1.1, the mean length of stay in this subgroup was 9.5 [5], and the mean number of home medications was 7.6 + 4.3.
Conclusion: Our study consisted of a thorough chart review of initially 350 patients. Based on exclusion criteria, the included sample size was 213, which is a decently sized sample. Our criteria allows for decent generalizability as it included any adult discharged from mobile infirmary in the span of 3 months, however it did exclude incomplete lists as to focus on discharge medications. We also had to assume that the completed reconciliation was as accurate as possible. This was also a single-center study, though at a large community hospital, and was retrospective, so there was a lack of true control. In conclusion, our study shows that medication discrepancies can still occur at discharge despite a completed prior to admission list, and the medications that have errors are high-risk medications. Future directions include scoring tools, artificial intelligence, and prioritizing the assessment of home medications while on disciplinary rounds. We are hopeful that this study procures a dedicated pharmacist-led reconciliation team and additional medication reconciliation protocols at discharge.