Table 4 Medication-related problems identified by students during the medication reconciliation patient project

Therapeutic Duplication

6

2 proton pump inhibitors (2), 2 statins, 2 beta blockers (3)

Therapeutic Omission at Discharge

8

Clopidogrel, Ramipril, Ranitidine, Vitamin B12 injection, Budesonide, Lisinopril, Tums, Prenatal vitamins, Carvedilol

Patient Did Not Take Medications Listed in Electronic Health Record (Non-Adherence)

11

Lisinopril, Bupropion, Aspirin, Multivitamin, Pantoprazole (2), Omeprazole, Metformin, Levothyroxine, Ergocalciferol, Pravastatin, Furosemide, Bactrim, Antipsychotic

Medications Used by Patients but Not Listed in Electronic Health Record

14

Fiber, Bisacodyl, Pantoprazole, Pravastatin, Magnesium, Vitamin B, Ciprofloxacin, Reservatol, CoQ-10, Ramipril, Ondansetron, Tylenol, Vitamin B-12, Tramadol, Aspirin, Glyburide, Ventolin, Multivitamin, Dexamethasone

Discharge List Included a Drug that Should Have Been Discontinued

1

Griseofulvin

Dosage too High

4

Warfarin, Aspirin, Oxycodone, Clonidine

Dosage too Low

9

Furosemide, Omeprazole, Doxycycline, Levothyroxine, Insulin, Hydrochlorothiazide, Gabapentin, Glimepiride, Lisinopril, Welchol

Drug-Disease Interaction

2

Omeprazole, Diclofenac

Drug-Drug Interaction

16

Amlodipine-simvastatin (2)

Oxybutynin-potassium

Escitalopram-pantoprazole

Methotrexate-pantoprazole

Sulfamethoxazole/trimethoprim-methotrexate

Potassium-spironolactone

Hydrochlorothiazide-vitamin D

Hydrochlorothiazide -NSAIDs

Aspirin-furosemide

Fluconazole-citalopram

Risperdone-ropinerole

Warfarin (unspecified)

Currently Having an Adverse Drug Event

16

Omeprazole, Warfarin (3), Simvastatin, Metoprolol, Lasix, Amlodipine, Lisinopril, Insulin, Glimepiride, Antiretroviral, Clonidine, Tramadol, Tobramycin, Pravastatin, Hydrochlorothiazide, Medroxyprogesterone, Metformin, Risperidone

Lack of Indication for Medication

6

Omprepazole, Promethazine, Reservatol, Vitamin E, CoQ10, Wellbutrin, Cinnamon, Colchicine, Viagra

Previously documented allergy, intolerance, or side effect

1

Tenofovir

Taking brand when generic is available

1

Simvastatin