What question did this study set out to answer?

The aim is to evaluate the effectiveness of a multidisciplinary medication reconciliation service in reducing medication discrepancies in older adults undergoing thoracic surgery.

March 28, 2026Open Access

Impact of multidisciplinary medication reconciliation service in older adult patients undergoing thoracic surgery (MERITS) on reducing medication discrepancies: a prospective, controlled, before-and-after study

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Thoracic surgery in older adults on chronic medication (n=324). Intervention: Multidisciplinary medication reconciliation (MedRec) service vs. Usual care. Primary outcome: Medication discrepancies at admission (p=<0.05).

Key Result

The multidisciplinary medication reconciliation service reduced medication discrepancies at admission from 62.0% to 2.8% and at discharge from 46.3% to 0.9% compared to usual care.

Key Points

The aim is to evaluate the effectiveness of a multidisciplinary medication reconciliation service in reducing medication discrepancies in older adults undergoing thoracic surgery.
Single-center prospective study comparing MedRec service and usual care
216 patients in the MedRec group and 108 in the usual care group
Pharmacists documented best possible medication history upon admission
Measured discrepancies at admission and discharge, drug-related problems, and healthcare visits post-discharge
Medication discrepancies significantly lower in intervention group at admission (2.8% vs. 62.0%) and discharge (0.9% vs. 46.3%)
Lower incidence of drug-related problems in intervention group (14.8% vs. 32.4%)
No significant differences in emergency visits (6.5% vs 4.6%) or unplanned readmissions (3.7% vs 6.5%)
High acceptance rates of pharmacist interventions at admission (98.8%) and discharge (96.6%)

Study Design

Type

Observational (n=324)

Multicenter

Structured PICO

Does a multidisciplinary medication reconciliation service reduce medication discrepancies in older adults undergoing thoracic surgery?

Population

Older adults (aged 65 years or older) undergoing thoracic surgery who were on chronic medication

Intervention

Multidisciplinary medication reconciliation (MedRec) service led by pharmacists (obtaining Best Possible Medication History upon admission, resolving discrepancies, and providing discharge counseling)

Comparator

Usual care (nurses documenting pre-admission medications, with retrospective pharmacist review post-discharge)

Outcome

Medication discrepancies between the Best Possible Medication History (BPMH) and physician orders at admission and dischargesafety

A multidisciplinary medication reconciliation service significantly reduces medication discrepancies and drug-related problems during care transitions for older adults undergoing thoracic surgery.

Main Result

Absolute Event Rate: 2.8% vs 62%

p-value: p=<0.05

Limitations

Single-center approach limits generalizability
Lack of randomization due to before-and-after design
Potential Hawthorne effect where medical staff awareness of the study may have influenced usual care
Potential recall bias due to reliance on patient accounts for documenting medication histories
Inability to directly verify all drug-related problems by medical records post-discharge
Relatively non-frail cohort may underestimate the impact of the service
COVID-19 pandemic delayed patient recruitment

Abstract

While medication reconciliation (MedRec) is a standard practice in many countries, it is not yet established in Korea. To bridge this gap, we introduced and evaluated a multidisciplinary MedRec service in older adults undergoing thoracic surgery. This single-center prospective study compared the MedRec service (216 patients, September 2022–August 2023) with the usual care group (108 patients, December 2021–April 2022) in older adults undergoing thoracic surgery who were on chronic medication. In the MedRec service, pharmacists obtained the best possible medication history (BPMH) upon admission for use in patient care, unlike usual care, where BPMH was documented post-discharge. Outcomes measured included medication discrepancies at admission and discharge, drug-related problems (DRPs), healthcare visits (emergency department, outpatient clinic and unplanned readmission) within one-month after discharge. Medication discrepancies were significantly lower in the intervention group than in the control group at both admission (62.0% vs. 2.8%, p < 0.05) and discharge (46.3% vs. 0.9%, p < 0.05). The incidence of DRPs was also lower in the intervention group within the first month post-discharge (32.4% vs. 14.8%, p < 0.05). However, no significant differences were noted in the rates of emergency department visits (6.5% vs 4.6%, p = 0.66) or unplanned readmissions (3.7% vs 6.5%, p = 0.44). In the intervention group, 887 interventions were performed at admission and 88 interventions at discharge, with acceptance rates of 98.8% and 96.6%, respectively. The multidisciplinary MedRec service effectively reduced medication discrepancies and DRPs during care transitions. Furthermore, it underscored the importance of pharmacist-led counseling in establishing BPMH and the positive impact of multidisciplinary approach in enhancing medication safety during these transitions. This study was registered with the Clinical Research Information Service KCT0006813.

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