This study evaluates the the effectiveness of pre-consultation Medication Reconciliation Service in reducing unintentional medication discrepancies among patients who discharged from hospital to primary care.

Medication discrepancies during care transition were common. Many factors contribute to the risk of medication discrepancies. Despite medication reconciliation service being practiced in the hospital setting, there was limited knowledge on its effectiveness in the primary care setting. This study aims to evaluate the effectiveness of a pre-consultation medication reconciliation service in reducing medication discrepancies in patients who transit from hospital to primary care. Adult patients who made their first visit to the polyclinics following a recent hospital discharge and were prescribed with 5 or more chronic medications were randomised to 2 groups. Pre-consultation medication reconciliation by a pharmacist was carried out for the intervention group. Outcome was assessed by a different pharmacist who was blinded to the randomised allocation. The control group underwent usual care without a pre-consultation medication reconciliation.

Inclusion Criteria:

1. Age 21 years and older
2. Patient or primary caregiver was able to provide informed consent
3. Patient or primary caregiver was English, Mandarin or Malay speaking
4. Patient was able to self-administer medications, or accompanied by a caregiver who assisted in administering medications
5. Patient was prescribed 5 or more chronic medications
6. The day of the study visit was the first follow-up visit in National Healthcare Group Polyclinics for chronic disease management after recent discharge from a local public hospital

Exclusion Criteria:

1. Residents of nursing home
2. The day of the study visit was for acute illness consult
3. Unwilling to consent to a 30-day follow-up phone call.