Impact of Pharmacist-Led Medication Reconciliation on Medication Discrepancies and Patient Safety During Transitions of Care: An Updated Systematic Review and Quantitative Descriptive Synthesis

Medication discrepancies are common during admission, transfer, and discharge. Pharmacists and pharmacy technicians can obtain best possible medication histories, identify discrepancies, communicate corrections, counsel patients, and support post-discharge continuity. To synthesize contemporary international and Saudi evidence on the effectiveness of pharmacist- or pharmacy-led medication reconciliation for reducing medication discrepancies, clinically important medication errors, and subsequent healthcare utilization during transitions of care. An updated PRISMA 2020-aligned systematic-review draft was developed from PubMed-indexed and publisher-verified reports available through 29 August 2026. Comparative and implementation studies involving adult transitions of care and pharmacist/pharmacy-team medication reconciliation were mapped. Outcomes, settings, sample sizes, effects, and limitations were extracted. Because outcome definitions, intervention components, transition points, and effect measures were heterogeneous, estimates were synthesized narratively and displayed descriptively without a new pooled meta-analysis. Twelve core reports were included in the current evidence map, five from Saudi Arabia. A prior meta-analysis of 19 studies found fewer patients with discrepancies after single-transition interventions (RR 0.34, 95% CI 0.23–0.50), but not conclusively after multiple-transition interventions (RR 0.88, 95% CI 0.77–1.02). Saudi studies consistently identified high discrepancy burdens, with 42.4%–48.3% of selected admissions having at least one unintended discrepancy. A 2024 pragmatic controlled trial reported clinically important discharge errors in 9.3% versus 61.9%, but no improvement in 30-day utilization. Across studies, evidence was stronger for medication-process outcomes than for readmission or emergency utilization. Pharmacist-led medication reconciliation improves detection and reduction of medication discrepancies, particularly at a clearly defined admission or discharge transition. Evidence that reconciliation alone reduces readmission or emergency utilization remains inconsistent. Saudi multicenter trials should integrate medication reconciliation with discharge counseling, communication, follow-up, and risk stratification while measuring patient-level harm and utilization.