Evaluating time-based outcomes of a pharmacist-doctor collaborative discharge medication reconciliation model: an observational study.

Abstract

Introduction: Medication reconciliation at hospital discharge is essential to prevent medication discrepancies and ensure continuity of care. Competing clinical priorities often delay reconciliation, reducing discharge efficiency and increasing the risk of medication-related harm. Collaborative pharmacist-doctor models have potential to improve the quality and timeliness of discharge medication processes.

Aim: To evaluate the impact of a pharmacist-doctor collaborative discharge medication reconciliation model on discharge timeliness, reconciliation quality, and pharmacist resource utilisation.

Method: This observational study was conducted in a large tertiary hospital across two inpatient units over 12 weeks: six weeks usual care (1 September-12 October 2025) followed by 6 weeks intervention (13 October-28 November 2025). In the intervention phase, clinical pharmacists performed reconciliation planning, which involved preparing the draft discharge medication reconciliation plan for subsequent medical officer review and authorisation. Time-and-motion methodology captured discrete intervals across the discharge workflow. Quantile regression analysed time-based outcomes, and Poisson regression evaluated count-based outcomes including prescription adjustments. The primary outcome was time from discharge confirmation to patient departure; secondary outcomes included reconciliation completion rates, prescribing adjustments, and pharmacist workload.

Results: A total of 116 patients were included (control n = 65; intervention n = 51). The collaborative model improved discharge efficiency, reducing the median time from discharge confirmation to leaving the ward by 78 min (p = 0.022). Time from decision to discharge to reconciliation completion was more than halved (30 vs 76 min, p < 0.001). Reconciliation completeness was significantly higher in the intervention group (90.2% vs 67.7%, p = 0.007), with fewer partial completions and no missing reconciliations. Analysis demonstrated earlier availability of discharge prescriptions (40 vs 80 min, p = 0.011) and shorter intervals between reconciliation completion and medication list preparation (14 vs 32 min, p = 0.008). Importantly, reconciliation planning by the pharmacist required a median of only 3 min per patient, confirming that improved timeliness required minimal additional pharmacist resourcing.

Conclusion: A pharmacist-doctor collaborative discharge medication reconciliation model improved discharge efficiency and reconciliation accuracy without increasing pharmacist workload. These findings support broader implementation of collaborative models to enhance patient safety and hospital workflow performance. Further research should explore cost-effectiveness and patient-centred outcomes.