Response to Comment on “Medication Reconciliation by a Pharmacist in Patients With Human Immunodeficiency Virus on Antiretroviral Therapy: The Needed Balance of Availability and Expertise”

TO THE EDITOR: We thank the authors for their insightful comments on our recent literature review of antiretroviral therapy (ART) and medication errors in hospitalized HIV-positive patients. ¹ The authors provide additional data to support the role of the pharmacist in performing medication reconciliation in an effort to decrease drug-related error in this population. ² They describe the success of using a nonspecialized pharmacist, who was trained and supported by a pharmacist specialized in infectious diseases/HIV, to conduct medication reconciliation within 48 hours of admission. Similar to results described by Corrigan et al, ³ they also report an increase in the detection of drug errors with pharmacist-driven medication history as compared with other health care professionals.

In our review we concluded that the most successful studies involved medication reconciliation performed within 24 hours of admission, preferably by a designated HIV or infectious diseases pharmacist, along with continual monitoring throughout the course of hospitalization and at discharge. In addition, other strategies such as education of the health care team and technology and formulary alerts/updates were also beneficial. ¹

Although the involvement of a specialized HIV or infectious diseases pharmacist is likely optimal for performing medication reconciliation in HIV patients, we agree that this is not always feasible, and other models of care should be explored. As reported by Jodlowski and Tam, ² a trained and supported nonspecialized clinical pharmacist is also capable of decreasing medication error in this population. It is paramount, however, that specialized HIV/ART education and ongoing HIV consultation and mentorship is available to support nonspecialized pharmacists in this initiative. As described by Commers et al, ⁴ 55% of ART errors were never detected during admission in their institution, despite medication reconciliation performed by a floor pharmacist within 24 hours of admission. The authors hypothesized that this low error detection rate was a result of a combination of incomplete medication reconciliation by the floor pharmacist and failure by staff physicians to intervene on identified discrepancies. Although the floor pharmacist was able to complete medication reconciliation in this study, additional specialized training or external support may have optimized the error identification and correction process. The authors noted that detection of a medication omission within the first 24 hours led to a more detailed review of the patient’s medication list and identification of more errors. At this point, additional support and knowledge for the staff pharmacist would have been beneficial to optimize inpatient drug therapy. The authors state, “It is now almost unreasonable to expect all providers who may treat HIV-infected inpatients to be knowledgeable about ART. Proposed solutions should therefore involve multidisciplinary approaches to facilitate a rapid, standardized review and reconciliation of medications by experienced providers upon the admission of HIV-infected patients receiving ART.”^4(p266)

In our institution, we have recently developed a guide to assessing ART in HIV hospitalized patients aimed at supporting nonspecialized health care providers. Plans for multidisciplinary education and implementation are currently under way. In addition, we strive to provide seamless care when a patient is hospitalized. In this model, the ambulatory clinic HIV pharmacist is notified and liaises closely with the unit inpatient pharmacist to perform medication reconciliation on admission and support patient care throughout hospitalization and at discharge. In summary, we agree that pharmacist-driven medication reconciliation is key to decreasing drug error in HIV patients. However, to optimize error detection and correction beyond the initial medication reconciliation, ongoing efforts in training, education, and support for nonspecialized hospital pharmacists are required.