Unintended Medication Discrepancies (UMD) During Transfer Reconciliation in the Context of Low and Middle Income Countries: A Narrative Review
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Abstract
Unintended medication discrepancies (UMD) frequently occur during transitions of care, particularly in low- and middle-income countries (LMICs), where the healthcare system often lacks standardized protocols, integrated information systems, and trained clinical pharmacists. This narrative review aims to explore the prevalence, characteristics, and contributing factors of UMD across LMICs based on analysis of 10 selected studies. Omission was the most frequently reported type of discrepancy, especially among elderly patients with complex therapy regimens. Factors influencing the occurrence of UMD include polypharmacy, inadequate documentation, absence of medication reconciliation protocols, limited pharmacist involvement, and poor inter-facility communication. Despite systemic limitations, studies demonstrate that pharmacist-led interventions can significantly reduce the incidence of UMD, even in resource-limited settings. Comparative analysis with studies from developed countries reveals that digital tools, standardized policies, and integrated pharmacist roles greatly enhance medication safety during transitions of care. The review concludes that addressing UMD in LMICs requires a multi-faceted approach, including national policy development, pharmacist integration into clinical teams, implementation of context-appropriate digital systems, and strengthening pharmacy education. These strategies are crucial for improving patient safety and reducing preventable adverse drug events related to medication discrepancies.
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References
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital Background: Studies of hospitalized patients identify safety as a. Ann Intern Med 2003;138:161–7. DOI: https://doi.org/10.7326/0003-4819-138-3-200302040-00007
El Morabet N, Uitvlugt EB, van den Bemt BJF, van den Bemt PMLA, Janssen MJA, Karapinar-Çarkit F. Prevalence and Preventability of Drug-Related Hospital Readmissions: A Systematic Review. J Am Geriatr Soc 2018;66:602–8. https://doi.org/10.1111/jgs.15244. DOI: https://doi.org/10.1111/jgs.15244
Hannum SM, Abebe E, Xiao Y, Brown R, Peña IM, Gurses AP. Engineering care transitions: Clinician perceptions of barriers to safe medication management during transitions of patient care. Appl Ergon 2021;91. https://doi.org/10.1016/j.apergo.2020.103299. DOI: https://doi.org/10.1016/j.apergo.2020.103299
Dong PTX, Pham VTT, Nguyen TT, Nguyen HTL, Hua S, Li SC. Unintentional Medication Discrepancies at Admission Among Elderly Inpatients with Chronic Medical Conditions in Vietnam: A Single-Centre Observational Study. Drugs - Real World Outcomes 2022;9:141–51. https://doi.org/10.1007/s40801-021-00274-3. DOI: https://doi.org/10.1007/s40801-021-00274-3
Mekonnen AB, McLachlan AJ, Brien JAE. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: A systematic review and meta-analysis. BMJ Open 2016;6. https://doi.org/10.1136/bmjopen-2015-010003. DOI: https://doi.org/10.1136/bmjopen-2015-010003
Ganachari M, Parghi B. Discrepancies occurred during multiple care transition points in a tertiary care hospital in India. Asian J Pharm Clin Res 2022. https://doi.org/10.22159/ajpcr.2022.v15i6.44569.
Ayalew M, Seifu MF. Prevalence of medication discrepancies and associated factors at hospital admission in Ethiopia. Integr Pharm Res Pract 2020. https://doi.org/10.2147/IPRP.S251770.
Alghamdi DS, Alhrasen M, Kassem A, Alwagdani A, Tourkmani AM, Alnowaiser N, et al. Implementation of medication reconciliation at admission and discharge in Ministry of Defense Health Services hospitals: A multicentre study. BMJ Open Qual 2023;12:1–9. https://doi.org/10.1136/bmjoq-2022-002121. DOI: https://doi.org/10.1136/bmjoq-2022-002121
Aires-Moreno M, Alcântara Jr A, Silva E. Medication discrepancies in transition of care of pediatric patients in a Brazilian university hospital. Pharm Pract (Granada) 2021. https://doi.org/10.18549/PharmPract.2021.4.2159.
Nguyen T, Pham H. Medication discrepancies and their potential harms in Vietnamese geriatric patients. Geriatr Gerontol Int 2023. https://doi.org/10.1111/ggi.14622. DOI: https://doi.org/10.1111/ggi.14622
Tamiru A, Edessa D, Sisay M, Mengistu G. Magnitude and factors associated with medication discrepancies identified through medication reconciliation at care transitions of a tertiary hospital in eastern Ethiopia. BMC Res Notes 2018;11:1–7. https://doi.org/10.1186/s13104-018-3668-z. DOI: https://doi.org/10.1186/s13104-018-3668-z
Ofori-Asenso R, Agyeman AA. Patient safety in Sub-Saharan Africa: a narrative review. Int J Qual Heal Care 2019. https://doi.org/10.1093/intqhc/mzz091. DOI: https://doi.org/10.1093/intqhc/mzz091
Chiewchantanakit D, Meakchai A, Pituchaturont N, Dilokthornsakul P, Dhippayom T. The effectiveness of medication reconciliation to prevent medication error: A systematic review and meta-analysis. Res Soc Adm Pharm 2020;16:886–94. https://doi.org/10.1016/j.sapharm.2019.10.004. DOI: https://doi.org/10.1016/j.sapharm.2019.10.004
Gala P, Moshokgo V, Seth B, Ramasuana K, Kazadi E, M’buse R, et al. Medication Errors and Blood Pressure Control Among Patients Managed for Hypertension in Public Ambulatory Care Clinics in Botswana. J Am Heart Assoc 2020;9:1–10. https://doi.org/10.1161/JAHA.119.013766. DOI: https://doi.org/10.1161/JAHA.119.013766
Altawalbeh SM, Sallam NM, Al-Khatib M, Alshogran OY, Bani Amer MS. Clinical pharmacist-led medication reconciliation supplemented with medication review in admitted patients with chronic kidney disease: a cost-benefit analysis. BMJ Open 2025;15:1–9. https://doi.org/10.1136/bmjopen-2024-087232. DOI: https://doi.org/10.1136/bmjopen-2024-087232
Aronson J. Medication reconciliation. BMJ 2017;356:5336. https://doi.org/10.1136/bmj.i5336. DOI: https://doi.org/10.1136/bmj.i5336