This study aims to assess the effects of Pharmacist-led medication reconciliation on hospitalized elderly patients aged above 65 at a leading tertiary military hospital in Jordan.

A four-month randomized controlled trial was conducted at King Hussein Medical Hospital (KHMH), one of the Royal Military Medical Services (RMS) tertiary hospitals located in central Amman. During the study period, 128 patients were selected using convenience sampling. Later, medication histories were compared between pre-admission and admission records to obtain the Best Possible Medication History (BPMH) and identify medication discrepancies, which were categorized as either intentional (documentation errors) or unintentional discrepancies.

The already selected patients were randomly allocated into two groups (intervention and control groups). Then, Pharmacist-led medication reconciliation services were provided to the intervention group and standard care was provided to the control group. Also at discharge the number of medication discrepancies was documented. Linear regression analysis was performed to assess risk factors associated with the occurrence of unintentional discrepancies.

Within 30 days post-discharge, patients were assessed for any hospital re-admissions, emergency department visits and medication-related side effects.

Inclusion Criteria:

• Newly admitted patient within no more than 24 hours and anticipated to stay in the hospital for more than 48 hours.
• Geriatrics patients defined as those aged (≥65 years) (Orimo et al., 2006).
• Prescribed at least one chronic medication prior to the study admission.

Exclusion Criteria:

• Patient admitted to the critical care or isolation units or in unconscious or comatose states.
• Patients if they were discharged against medical advice.