Medication reconciliation: impact of an educational intervention on the knowledge, attitude and practices of healthcare professionals - a prospective quasi-experimental study in a Saudi referral hospital

Abstract

Background

Medication reconciliation has been acknowledged as a key intervention against medication errors. More than half of the medication errors that happen during care transitions are caused by unjustified medication discrepancies and up to one-third of these mistakes may be harmful. The study aimed to evaluate the knowledge, attitude and practices (KAP) of health care providers in on medication reconciliation process, pre and post educational intervention.

Methods

A hospital-based prospective quasi-experimental pre-post intervention study was conducted from November 2023 to February 2024 among 346 healthcare professionals (medical doctors, pharmacists and nurses) practicing in King Saud Hospital (KSH), Unayzah, Saudi Arabia. The subjects were recruited using the convenience sampling method.An educational intervention workshop was conducted among the healthcare professionals. The KAP was assessed before and after the educational intervention using a content and face validated self-administered questionnaire. The statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS). Wilcoxon Signed Rank Test was used to differentiate the mean response scores for knowledge, attitude, and practice domains, between pre and post intervention. Kruskal Wallis Test followed by Dunn’s post hoc test was used to compare the mean response scores for knowledge, attitude and practice domains based on educational qualification and practicing experience for the pre and post-test period. The level of significance is determined at P < 0.05.

Results

There was a significant improvement in the participants’ knowledge, attitude and practice after the educational intervention with mean scores of 0.72 (SD = 1.67, p < 0.0001*), 0.76 (SD = 1.97, p < 0.0001*), and 0.56 (SD = 2.05, p = 0.001*) respectively. The overall KAP scores showed a statistically significant enhancement after the education intervention with a mean score difference of 2.04 (SD = 4.76, p < 0.0001*).Our study upholds that MedRec is highly valued by the participants due to its significant role in reducing medication errors and enhancing patient safety, and that it has the ability to recognize medication discrepancies and reduce adverse drug events.

Conclusion

The education intervention effectively influenced the knowledge, attitude and practice of healthcare professionals regarding medication reconciliation. This study underscores the importance of continuous education and training for healthcare professionals to minimize medication discrepancies and improve patient care.

Introduction

Medication Reconciliation (MedRec) is the core foundation of modern healthcare and is an essential process for patient safety and optimization of healthcare outcomes. In essence, it is an organized review and documentation of a patient’s existing drug prescription to identify and resolve medication discrepancies, and encourage effective medication management [1, 2].

Medication discrepancies are the variations between two or more medication lists of a patient that can arise across the transitions of care including admission, transfer, discharge, and transfer to other healthcare settings. The discrepancies (such as drug omission, wrong dosage, or wrong route) could be intentional or unintentional, but are not recorded in the patients’ medical files.

In today’s healthcare scenario, patients frequently receive care from multiple healthcare providers in various settings, leading to fragmented medication histories as well as significant communication gaps. These gaps may contribute to medication errors, serious adverse drug reactions and compromised patient safety [3–5]. MedRec strives to address these gaps by generating a comprehensive and reliable medication list which includes prescription medications, over-the-counter drugs, vitamins, and herbal remedies [6–8].

The MedRec approach generally encompasses three steps: acquiring a complete medication history, verifying this information with current medication orders, and reconciling any discrepancies through communication with the patient, caretakers, and healthcare practitioners. By reconciling the list of medications across transitions of care, such as admission, in patient transfer, and discharge, healthcare teams can reduce the risk of drug-related problems and establish continuity of care [1, 9, 10].

Even though the MedRec process appears to be uncomplicated, its implementation during hospital admission, inpatient transfer, and discharge has been found to be cumbersome [11]. The process of collecting, arranging, and conveying the medication data is hindered by various factors, as reported in several studies from United States [12–15]. Adding to the complexity is the number of healthcare professionals concerned with the MedRec process which includes doctors, nurses, pharmacists, along with the patients and caregivers. Lack of standardized policies concerning the duties of each healthcare professional involved in MedRec leads to inadequate implementation and incompetence [16].Regarding the healthcare context in Saudi Arabia and other GCC countries, various studies have identified the challenges in implementing this process and they reported that inadequate knowledge, lack of regulations, time constraints, challenges in gaining access to patient records, lack of cooperation between healthcare professionals, and lack of patient’s awareness about his or her medications are the main challenges towards practicing MedRec [17–21].

Implementation of MedRec and its adherence among healthcare professionals requires a thorough understanding of the KAP [22]. Medication reconciliation provides a multitude of possibilities and challenges that are best captured by this intersection of knowledge, attitude, and practice. Knowledge encompasses understanding the intricacies of medication reconciliation protocols, its significance of appropriate prescription histories, and the complexities of medication reconciliation procedures. The attitudes of healthcare professionals towards medication reconciliation have an impact on their readiness to participate in the procedure, support its incorporation into clinical workflows, and prioritise patient safety [22]. Practice comprises the practical implementation of medication reconciliation practices in actual healthcare settings, necessitating efficient communication, teamwork, and optimal utilisation of resources [23].Thus, assessing the knowledge, attitude, and practices concerning medication reconciliation offers valuable insights to enhance its effectiveness and ultimately advance the quality and safety of healthcare delivery.

Educational interventions have proven to be effective in improving MedRec knowledge, attitude and practices among healthcare professionals these interventions have led to significant reductions in medication discrepancies and have shown promise in preventing medication-related harm to patients [24]. These interventions have showcased the potential to improve medication reconciliation practices among healthcare professionals, thereby contributing to the overall safety and effectiveness of patient care [25].

An extensive staff educational program was recommended by the WHO Standard Operating Protocol for Medication Reconciliation as a key factor for the success of medication reconciliation which would incorporate the training of new staff along with regular briefings [26]. In Canada, Kingston General Hospital conducts a brief medication reconciliation program for the house staff joining their residency programs [27]. Various MedRec educational interventions have been assessed primarily for medical trainees, which included hands-on sessions, simulations, and didactic programs [10]. However, most of the educational interventions have been targeted towards trainees rather than toward practicing healthcare professionals [28].

The existing evidence on the knowledge, attitude, and practices, related to MedRec process in Saudi Arabia is scanty [20, 29]. In addition, there are no studies conducted in Saudi Arabia that have employed an educational intervention on MedRec. Understanding the knowledge, attitude and practices can provide valuable information that can aid in the development of educational interventions to provide training to the healthcare professionals, and in turn improve patient care. Therefore, our study aims to evaluate changes in the knowledge, attitude, and practices related to the medication reconciliation (MedRec) process among healthcare providers in a Saudi referral hospital before and after an educational intervention.

Methods

Study site & study population

The study conducted at KSH Unayzah, Saudi Arabia from November 2023 to February 2024. It is the only major general referral government hospital in Unayzah city, Qassim region of Saudi Arabia. The study was conducted among healthcare professionals including medical doctors, pharmacists and nurses practicing at the hospital.

Study design

A hospital-based prospective, quasi-experimental, pre-post intervention study was performed among health care providers to evaluate the knowledge, attitude and practice (KAP) on medication reconciliation, before and after an educational intervention. The KAP was assessed using a self-administered questionnaire before and after the educational intervention. The content of the educational intervention was about MedRec process, its standard practices, implementation, and its significance in terms of reduction in the number of discrepancies, reduction of adverse drug reaction, its impact on the clinical outcomes, recent literature and recent trends.

Development of questionnaire

A new study questionnaire was developed with the help of extensive literature review and administered in English language. The questionnaire consisted of four parts assessing the demographic data, knowledge, attitude, and practice of MedRec. Ten questions with each domain of knowledge, attitu1de, and practice. The responses were categorized as Yes/No/don’t know, depending on the nature and scope of the question.The questionnaire was validated using Lawshe’s technique for content validation [30]. The questionnaire was evaluated by six panelists expert in the field, two clinical pharmacists from the Department of Pharmaceutical Care, two head nurses from the Department of Nursing, and two senior medical doctors from the Department of Internal Medicine, KSH Unayzah. Face validity was done by pre-testing the questionnaire among three pharmacists, three nurses and three medical doctors at KSH, Unayzah. Minor changes were made to enhance the clarity of some questions without altering their core.

A pilot study was performed prior to the study by circulating the questionnaire to 10% of the study participants, i.e., eleven medical doctors, four pharmacists, and thirty nurses [31]. This data was excluded from the study’s final results. The pilot study was carried out to assess the feasibility of the study and evaluate the reliability of the questionnaire. Cronbach alpha test was used to evaluate the reliability of the questionnaire for each domain. Cronbach’s alpha score 0.85 was achieved which is considered as good internal consistency [32]. The content validity ratio (CVR) was determined using Lawshe’s formula CVR=(ne-N2)/N/2 in which the N_e is the number of panelists indicating “essential” and N is the total number of panelists. CVR 0.99 was obtained in our study which was well above the determined cut off of 0.8. Survey was finalized for distribution using Google form survey link and distributed via education, training and research department of KSH Unayzah and follow up was done for both pre and post-test.

Procedure of education intervention

Education intervention training workshop was conducted at main auditorium of KSH, Unayzah among the healthcare professionals, consists of medical doctors, pharmacists and nurses. The training workshop was approved by Saudi Commission for Health Specialties with five Continuous Medical Education (CME) credit hours for attendees with activity accreditation number ACA-20230005397. The training workshop provided five free CME credit hours for participants, certificates from Ministry of Health Saudi Arabia, and also certificate of recognition for the trainers from the hospital facilitators. The workshop was self-funded and conducted on five topics which were as follows: (1) Understanding MedRec, (2) Roles and responsibilities of healthcare providers in MedRec, (3) Detailed patient medication history taking and conducting MedRec, (4) Best practice guidelines for MedRec and (5) Potential challenges encountered in MedRec and its implementation tools. The chosen content was structured to proceed sequentially, first explaining the rationale of MedRec and the steps involved in the MedRec process, followed by stating the responsibility of each healthcare professional, considering the disagreement among healthcare professionals in previous studies. Best possible medication history was described in the next session which forms the crux of the MedRec process. The guidelines given by various international organizations were presented in the fourth session, to showcase how MedRec is carried out globally. The last session included the common barriers encountered with its implementation, and the application of some tools to optimize the MedRec process.

Each session lasted one hour, with a total duration of five hours. The workshop was conducted using didactic lectures and presentation slides. Before the workshop, content of the education intervention lectures was evaluated by six panelists, two clinical pharmacists from the Department of Pharmaceutical Care, two head nurses from the department of Nursing, and two senior medical doctors from the Department of Internal Medicine, KSH, Unayzah using scale of EducationalContent Validation Instrument in Health, Fortaleza, Ceara, Brazil, 2017 [33].Minor amendments were done in the educational materials as per panelists opinion. The content validity ratio (CVR) was determined using Lawshe’s formula CVR=(ne-N2)/N/2 in which the N_e is the number of panelists indicating “essential” and N is the total number of panelists [34].CVR 0.99 was obtained in our study. Before the start of the educational intervention, the subjects were given a questionnaire on KAP to get their baseline KAP related to the MedRec and also after the end of the educational intervention to measure the post test.

Sampling method

The subjects were recruited using the convenience sampling method. The healthcare practitioners (medical doctors, pharmacists, and nurses) who fulfilled the inclusion and exclusion criteria were recruited into this study.

Inclusion criteria

Healthcare professionals practicing in the study hospital including medical doctors, nurses, and pharmacists.

Exclusion criteria

Housemen, students, interns and healthcare professionals who were not willing to participate in the study.

Sample size determination

Automated software program “Raosoft sample size calculator” (http://www.raosoft.com/samplesize.html) was used to calculate the required sample size for this study for each of the healthcare professional category from King Saud Hospital, Unayzah [35].

Where N is the population size, r is the predicted fraction of responses, and Z(c/100) is the critical value for the confidence level c, and E is the accepted margin of error.

Medical doctors

• For medical doctors, the estimated N is 110 (estimated from the hospital record), r is predicted as 50%, Z(c/100) is estimated at 95% and E as 5%, the minimum sample size required is 86.

Nurses

• For nursing professional, the estimated N is 300 (estimated from the hospital record), r is predicted as 50%, Z(c/100) is estimated at 95% and E as 5%, the minimum sample size required is 169.

Pharmacists

• For pharmacists, the estimated N is 35 (estimated from the hospital record), r is predicted as 50%, Z(c/100) is estimated at 95% and E as 5%, the minimum sample size required is 33.

Statistical analysis

The statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS) for Windows Version 22.0, released 2013, IBM Corp. Armonk, NY.

Descriptive statistics

The descriptive statistics were calculated using frequency and percentage for categorical variables, and mean, +/-SD, SE for continuous variables.

Inferential statistics

Wilcoxon Signed Rank Test was used to differentiate the mean response scores for knowledge, attitude, and practice domains, including the total KAP score between pre and post intervention. Kruskal Wallis Test followed by Dunn’s post hoc test was used to compare the mean response scores for knowledge, attitude and practice domains including the total KAP based on educational qualification and practicing experience for the pre and post-test period. The level of significance is determined at P < 0.05.

Results

Sociodemographic results

Four hundred and forty-five (445) questionnaires were distributed of which 360 participants responded to the pre-test education intervention (pre-test) and 346 participants responded to the post-test education intervention (post-test), resulting in a response rate of 80.9% for pre-test and 77.7% for post-test, respectively.14 participants of pre-test were excluded only during comparison of pre & post-test of each domain (KAP) as the 14 participants did not respond to post test survey.

The study sample for pre-test consisted of 30.6% medical doctors (n = 107), 9.7% pharmacists (n = 34), 62.3% nurses (n = 218) and the profession of 0.4% (n = 1) was not mentioned by the participant during pre-test. The study sample for post-test included 29.5% (n = 102) medical doctors, 9.5% (n = 33) pharmacists, 61% (n = 211) nurses. The sociodemographic characteristics of the participants are illustrated in Table 1.

Table 1.

Distribution of sociodemographic characteristics among study participants during Pre-test & Post-test assessment

Variable	Category	Pre Test N = 360		Post Test N = 346
		n	%	n	%
Profession	Medical Doctor	107	30.6%	102	29.5%
	Pharmacist	34	9.7%	33	9.5%
	Nurse	218	62.3%	211	61.0%
	Not Available	1	0.4%	0	0. 0%
Gender	Males	114	31.7%	109	31.5%
	Females	246	68.3%	237	68.5%
Age (Years)	21–30 yrs.	97	26.9%	93	26.9%
	31–40 yrs.	143	39.7%	141	40.8%
	41–50 yrs.	79	21.9%	77	22.3%
	51–60 yrs.	32	8.9%	28	8.1%
	> 60 yrs.	9	2.5%	7	2.0%
Nationality	Saudi	91	25.3%	86	24.9%
	Non-Saudi	269	74.7%	260	75.1%
Profession Qualification	Diploma	49	13.6%	45	13.0%
	Bachelor	219	60.8%	214	61.8%
	Masters	46	12.8%	43	12.4%
	Fellowship	35	9.7%	33	9.5%
	PhD	11	3.1%	11	3.2%
Years of Practicing Experience	0–10 yrs.	186	51.7%	179	51.7%
	11–20 yrs.	125	34.7%	121	35.0%
	21–30 yrs.	39	10.8%	37	10.7%
	> 30 yrs.	10	2.8%	9	2.6%

The results revealed that in the pre-test phase, 68.3% (246) of the participants were females, and 39.7% (143) were aged between 31 and 40 years. Nationality-wise, non-Saudis represented 74.7% (269) of the participants. In qualification highest was a Bachelor’s degree amongst 60.8% (219) of the participants. 51.7% (186) of the participants had work experience between 0 and 10 years, while 34.7% (125) have 11–20 years, 10.8% (39) with 21–30 years of experience, and 2.8% (10) with more than 30 years.

In the post-intervention phase, most participants were females (68.5%, n = 237), and aged between 31 and 40 years (40.8%, n = 141). Non-Saudis (75.1%, n = 260) represented majority of the study sample. In qualification also highest was a Bachelor’s degree among 61.8% (n = 214) of the participants. More than half of the participants (51.7%, n = 179) had work experience between 0 and 10 years. (Table 1).

Comparison of knowledge of participants about MedRec pre and post education intervention (table 2)

Table 2.

Distribution of pre-and post-test responses to knowledge- based questions on MedRec among study participants

Variable	Category	Pre-Test (N = 360)		Post Test (N = 346)
		n	%	n	%
Q1: Do you know about medication reconciliation and its practices?	Yes	312	86.7%	330	95.4%
	No	29	8.1%	10	2.9%
	Don’t know	19	5.3%	6	1.7%
Q2: Is medication reconciliation important in the patient care process?	Yes	345	95.8%	339	98.0%
	No	1	0.3%	3	0.9%
	Don’t know	14	3.9%	4	1.2%
Q3: Is it important that medication reconciliation should be done at every transition care?	Yes	331	91.9%	328	94.8%
	No	7	1.9%	7	2.0%
	Don’t know	22	6.1%	11	3.2%
Q4: Does medication reconciliation lead to reduction in patient harm?	Yes	333	92.5%	332	96.0%
	No	9	2.5%	5	1.4%
	Don’t know	18	5.0%	9	2.6%
Q5: Do you think that a patient’s medication list is an accurate reflection of the medications they are taking?	Yes	259	72.3%	278	80.6%
	No	53	14.8%	34	9.9%
	Don’t know	46	12.8%	33	9.6%
Q6: Can you overcome the barriers in communicating with your patients about their medications after this course?	Yes	150	41.7%	187	54.0%
	No	188	52.2%	142	41.0%
	Don’t know	22	6.1%	17	4.9%
Q7: Are you aware about your role and your responsible for in the medication reconciliation process?	Yes	257	71.4%	296	85.8%
	No	51	14.2%	31	9.0%
	Don’t know	52	14.4%	18	5.2%
Q8: Which type of form will you use for medication reconciliation process use?	Paper	85	23.6%	91	26.3%
	Computerized Charts	231	64.2%	238	68.8%
	Don’t know	44	12.2%	17	4.9%
Q9: Have you received training on medication reconciliation while pursuing your university degree?	Yes	156	43.3%	162	46.8%
	No	171	47.5%	166	48.0%
	Don’t know	33	9.2%	18	5.2%
Q10: Is this training that you received training medication reconciliation sufficient?	Yes	172	47.8%	210	60.7%
	No	166	46.1%	110	31.8%
	Don’t know	22	6.1%	26	7.5%

Before the education intervention, most participants (n = 312; 86.7%) reported being familiar with medication reconciliation and its practices (Table 2). 95.8% (n = 345) of the participants stated that MedRec was important in the patient care process and 91.9% (n = 331) agreed that medication reconciliation should be done at every transition care. Majority of the participants correctly answered that medication reconciliation led to reduction in patient harm (92.5%; n = 333), while only 72.3% (n = 269) answered that a patient’s medication list is a precise reflection of the medications they are taking. 52.2% (n = 188) of the participants thought that they would not be able to overcome the barriers in communicating with patients about their medications after the intervention, while 41.7% (n = 150) thought that they could overcome the barriers after the intervention. Moreover, only 71.4% (n = 257) of the participants were aware about their roles and responsibilities in the medication reconciliation process. Regarding the use of forms in the medication reconciliation process, computerized charts were used by 64.2% (n = 231) and paper-based forms were used by 23.6% (n = 85), while 12.2% (n = 44) did not know the type of forms being used. Less than half of the participants received training on MedRec while pursuing their university degree (43.3%; n = 156), and the training received was considered to be insufficient (47.8%; n = 172).

After the education intervention, a greater number of participants reported being familiar with medication reconciliation and its practices (94.8%; n = 328) (Table 2). More participants (80.6%; n = 278) agreed that a patient’s medication list is a precise reflection of the medications they are taking. More than half of the participants (54%; n = 187) believed that they could overcome the barriers in communicating with patients about their medications after this course. A vast majority of the participants (85.8%; n = 296) were now aware about their roles and responsibilities in the medication reconciliation process. 60.7% (n = 210) of the participants considered the training received for medication reconciliation to be sufficient.

Comparison of attitude of participants towards MedRec pre and post education intervention (table 3)

In response to the attitude questions raised in the questionnaire during the pre-test phase, only 75.6% (n = 272) of the participants believed that conducting medication reconciliation was their responsibility. Less than half of the participants (49%; n = 176) reported that they did not experience any barriers that might discourage them from implementing medication reconciliation services. 73.9% (n = 266) believed that they had good communication pertaining to medication reconciliation with other healthcare providers at the hospital. However, a significant proportion (44.6%; n = 160) of the participants faced barriers in communicating with patients about their medications. A vast majority of the participants (86.9%; n = 313) agreed that they would like to have a standardized process for medication reconciliation at their hospital. Regarding the addition or removal of medications from a patient’s medication list, 66.4% (n = 239) were comfortable in adding medications while only 54.4% (n = 196) were comfortable in removing medications from a patient’s medication list during medication reconciliation. Most of the participants thought that the medication history and reconciliation process provided reliable information (85%; n = 305), which leads to better medication orders being written (86.4%; n = 311), and the individual suggests that they would greatly benefit from additional training on medication reconciliation. (81.8%; n = 293) (Table 3).

Table 3.

Distribution of pre and post-test responses to attitude-based questions on MedRec among study participants

Variable	Category	Pre Test N = 360		Post Test N = 346
		n	%	n	%
Q1: Do you believe that it is your responsibility to conduct medication reconciliation?	Yes	272	75.6%	291	84.1%
	No	38	10.6%	32	9.2%
	Don’t know	50	13.9%	23	6.6%
Q2: Do you experience any barriers that might discourage you from implementing medication reconciliation services?	Yes	127	35.4%	129	37.3%
	No	176	49.0%	186	53.8%
	Don’t know	56	15.6%	31	9.0%
Q3: Do you have good communication pertaining to medication reconciliation with other healthcare providers at your hospital?	Yes	266	73.9%	277	80.1%
	No	44	12.2%	50	14.5%
	Don’t know	50	13.9%	19	5.5%
Q4: Do you face any barriers in communicating with your patients about their medications?	Yes	160	44.6%	146	42.2%
	No	177	49.3%	187	54.0%
	Don’t know	22	6.1%	13	3.8%
Q5: Would you like to have a standardized process for medication reconciliation at your hospital?	Yes	313	86.9%	325	93.9%
	No	11	3.1%	4	1.2%
	Don’t know	36	10.0%	17	4.9%
Q6: Are you comfortable in adding medications to a patient’s medication list during medication reconciliation?	Yes	239	66.4%	273	78.9%
	No	59	16.4%	43	12.4%
	Don’t know	62	17.2%	30	8.7%
Q7: Are you comfortable in removing medications from a patient’s medication list during medication reconciliation?	Yes	196	54.4%	225	65.0%
	No	92	25.6%	80	23.1%
	Don’t know	72	20.0%	41	11.8%
Q8: Do you think that the medication history and reconciliation process provide reliable information?	Yes	305	85.0%	320	92.5%
	No	18	5.0%	4	1.2%
	Don’t know	36	10.0%	22	6.4%
Q9: Do you think that the medication history and reconciliation process leads to better medication orders being written?	Yes	311	86.4%	329	95.1%
	No	13	3.6%	4	1.2%
	Don’t know	36	10.0%	13	3.8%
Q10: Do you think you would benefit from additional training on medication reconciliation?	Yes	293	81.8%	323	93.4%
	No	24	6.7%	11	3.2%
	Don’t know	41	11.5%	12	3.5%

In the post-test phase, more participants believed that it is their responsibility to conduct medication reconciliation (84.3%; n = 291). More than half of the participants (53.8%; n = 186) now reported that they did not experience any barriers that might discourage them from implementing medication reconciliation services. A greater number of participants felt comfortable in adding (78.9%; n = 273) and removing (65.4%; n = 225) medications from a patient’s medication list during medication reconciliation. 93.6% (n = 323) of the participants agreed that they would benefit from additional training on medication reconciliation (Table 3).

Comparison of MedRec practices pre and post education intervention (table 4)

Table 4.

Distribution of pre- and post-test responses to practice-based questions on MedRec among study participants

Variable	Category	Pre Test N = 360		Post Test N = 346
		n	%	n	%
Q1: Do you usually obtain a best possible medication history from patients when they arrive at your facility?	Yes	274	76.1%	295	85.3%
	No	47	13.1%	27	7.8%
	Don’t know	39	10.8%	24	6.9%
Q2: Do you reconcile medications upon transfer of a patient to another level of care/unit?	Yes	282	78.3%	293	84.7%
	No	24	6.7%	36	10.4%
	Don’t know	54	15.0%	17	4.9%
Q3: Do you reconcile medications at the time of discharge?	Yes	287	79.7%	290	83.8%
	No	25	6.9%	34	9.8%
	Don’t know	48	13.3%	22	6.4%
Q4: Do you provide and instructions on use of medications for patients upon discharge?	Yes	307	85.3%	317	91.6%
	No	24	6.7%	10	2.9%
	Don’t know	29	8.1%	19	5.5%
Q5: Do you have any time restrictions when performing medication reconciliation?	Yes	152	42.2%	159	46.0%
	No	142	39.4%	144	41.6%
	Don’t know	66	18.3%	43	12.4%
Q6: Do you record the dose, route, frequency and length of the therapy for each medication that is delivered to the patients?	Yes	324	90.0%	327	94.5%
	No	13	3.6%	11	3.2%
	Don’t know	23	6.4%	8	2.3%
Q7: Do you record or observe patients who are taking overlapping/omitted/duplicate medications?	Yes	270	75.0%	296	85.5%
	No	46	12.8%	30	8.7%
	Don’t know	44	12.2%	20	5.8%
Q8: Do you record or observe an error during medication reconciliation which could cause potential harm to the patient?	Yes	267	74.2%	253	73.1%
	No	50	13.9%	79	22.8%
	Don’t know	43	11.9%	14	4.0%
Q9: Have you ever identified an error during medication reconciliation which did cause harm to the patient?	Yes	160	44.6%	137	39.6%
	No	155	43.2%	186	53.8%
	Don’t know	44	12.3%	23	6.6%
Q10: Do you have the necessary support and resources to perform medication reconciliation from the hospital management?	Yes	246	68.3%	279	80.6%
	No	48	13.3%	18	5.2%
	Don’t know	66	18.3%	49	14.2%

During the pre-test phase, most participants (n = 274; 76.1%) reported obtaining the best possible medication history from patients on arrival at the facility, as well as reconciling medications upon transfer of a patient to another level of care/unit (n = 282; 78.3%), and at the time of discharge (n = 287; 79.7%). Besides, instructions on use of medications were also provided to patients upon discharge by 85.3% (n = 308) of the participants. Time restrictions were experienced by 42.2% (n = 152) of the participants when performing medication reconciliation. A vast majority of the participants (90%; n = 324) recorded the dose, route, frequency and length of the therapy for each medication that is delivered to the patients, however fewer participants (75%; n = 270) recorded patients who are taking overlapping/omitted/duplicate medications, as well as the errors during medication reconciliation which could cause potential harm to the patient (74.2%; n = 267). Less than half of the participants (44.6%; n = 160) had ever identified an error during medication reconciliation which did cause harm to the patient. Additionally, 68.3% (n = 246) of the participants indicated that they were provided with the necessary support and resources to perform medication reconciliation from the hospital management (Table 4).

More participants (n = 295; 85.3%) reported obtaining the best possible medication history from patients on arrival at the facility in the post-test phase. 91.9% (n = 317) of the participants were now providing instructions on use of medications for patients upon discharge. Majority of the participants (46%, n = 159) felt that they experienced time restrictions when performing medication reconciliation after the intervention. A greater number of participants (85.8%; n = 296) recorded patients who are taking overlapping/omitted/duplicate medications. Most participants (80.6%; n = 279) also declared that they had the necessary support and resources to perform medication reconciliation from the hospital management (Table 4).

Comparison of mean response scores for knowledge, attitude & practice domains

Post-test, the scores for knowledge of medication reconciliation with education intervention were significantly enhanced with a mean score difference of 0.72 (p < 0.0001) (Table 5). There was a statistically significant enhanced in the attitude of the research participants towards MedRec with a mean difference of 0.76 (p < 0.0001) (Table 5). The intervention also showed a significantly positive impact on the MedRec practice scores of research participants with a mean difference of 0.56 (p = 0.0010) (Table 5). The overall KAP scores manifest a statistically significant enhancement after the education intervention with a mean difference of 2.04 (p < 0.0001).

Table 5.

Comparison of mean response scores for knowledge, attitude and -practice (KAP) domains including total KAP between pre and post-test using wilcoxon signed Rank Test

Domains	Time	N	Mean	SD	Mean Diff	Cohen’s d	p-value
Knowledge	Pre Test	346	6.40	1.89	0.72	0.4103	0.0001*
	Post Test	346	7.12	1.62
Attitude	Pre Test	346	6.86	2.38	0.76	0.3494	0.0001*
	Post Test	346	7.62	1.97
Practice	Pre Test	346	7.09	2.68	0.56	0.2368	0.0010*
	Post Test	346	7.65	2.05
KAP	Pre Test	346	20.35	5.89	2.04	0.3795	0.0001*
	Post Test	346	22.39	4.76

p < 0.05* - Statistical significance

Comparison of mean KAP scores based on the educational qualification of study participants during the pre & post education test period (Table 6)

Table 6.

Comparison of mean KAP scores based on the educational qualification of study participants during the pre &post test period using Kruskal Wallis Test

Pre-Test Period KAP scores for Education Qualification of Study participants ( N  = 360)
Domains	Qualification	N	Mean	SD	Min	Max	p-value
Knowledge	Diploma	49	6.27	2.28	0	9	0.001*
	Bachelor	219	6.69	1.74	0	9
	Masters	46	5.46	2.05	0	9
	Fellowship	35	6.37	1.61	3	9
	PhD	11	6.00	1.95	3	9
Attitude	Diploma	49	6.73	2.56	0	10	0.02*
	Bachelor	219	6.84	2.26	0	10
	Masters	46	6.52	2.85	0	10
	Fellowship	35	8.00	2.06	2	10
	PhD	11	6.82	1.66	3	9
Practice	Diploma	49	7.20	3.00	0	10	0.32
	Bachelor	219	7.19	2.49	0	10
	Masters	46	6.35	3.25	0	10
	Fellowship	35	7.77	2.16	1	10
	PhD	11	6.91	2.51	1	9
KAP	Diploma	49	20.20	7.15	0	29	0.13
	Bachelor	219	20.72	5.45	0	29
	Masters	46	18.33	6.93	0	28
	Fellowship	35	22.14	4.79	9	29
	PhD	11	19.73	4.65	10	25
Post-Test Period KAP scores for Education Qualification of Study participants ( N  = 346)
Domains	Experience	N	Mean	SD	Min	Max	p-value
Knowledge	Diploma	45	6.51	1.98	0	9	0.06
	Bachelor	214	7.37	1.32	2	9
	Masters	43	6.88	2.06	0	9
	Fellowship	33	6.88	1.71	2	9
	PhD	11	6.18	2.23	0	8
Attitude	Diploma	45	6.84	2.59	0	10	0.06
	Bachelor	214	7.64	1.76	1	10
	Masters	43	7.98	2.24	0	10
	Fellowship	33	7.97	1.67	3	10
	PhD	11	8.00	2.19	3	10
Practice	Diploma	45	6.98	2.21	0	10	0.09
	Bachelor	214	7.77	1.97	0	10
	Masters	43	7.42	2.58	0	10
	Fellowship	33	8.15	1.70	5	10
	PhD	11	7.45	1.13	6	9
KAP	Diploma	45	20.33	6.13	2	29	0.09
	Bachelor	214	22.79	4.02	7	29
	Masters	43	22.28	6.30	1	29
	Fellowship	33	23.00	4.42	15	29
	PhD	11	21.64	4.18	11	26

p < 0.05* - Statistical significance

Knowledge domain

Multiple comparison using Dunn’s Post hoc Test revealed that the mean difference in the knowledge scores during pre-test phase showed the participants with Bachelor degree had higher mean knowledge scores while those with master’s degree had significantly lesser mean knowledge scores and the mean differences were statistically significant (p = 0.001). The results were similar in the post-test phase; however, the difference was not statistically significant between different educational qualifications.

Attitude domain

Multiple comparison using Dunn’s Post hoc Test revealed that the multiple comparison of mean Attitude scores during pre-test phase showed the participants with Fellowship qualification had significantly higher mean Attitude scores as compared to those with Diploma, Bachelor, Masters and PhD degrees and the mean differences were statistically significant (p = 0.02). In the post-test phase, the participants with PhD had higher mean attitude scores; however, the difference was not statistically significant.

Practice domain

Multiple comparison using Dunn’s Post hoc Test revealed that the mean difference in the practice scores during pre-test phase showed the participants with Fellowship had higher mean practice scores (mean = 7.77) as compared to those with other educational qualifications, the difference was not statistically significant. The results were similar in the post-test phase; the difference was not statistically significant between different educational qualifications.

Comparison of mean KAP scores based on the practicing experience of study participants during the pre & post-test phase (Table 7)

Table 7.

Comparison of mean KAP scores based on the practicing experience of study participants during the pre& post-test period using Kruskal Wallis Test

Pre-test period KAP scores for experience of study participants N = 360
Domains	Experience	N	Mean	SD	Min	Max	p-value
Knowledge	0–10 yrs.	186	6.55	1.73	0	9	0.51
	11–20 yrs.	125	6.24	1.99	0	9
	21–30 yrs.	39	6.28	2.35	0	9
	> 30 yrs.	10	7.00	1.56	4	9
Attitude	0–10 yrs.	186	6.83	2.22	0	10	0.47
	11–20 yrs.	125	6.85	2.60	0	10
	21–30 yrs.	39	7.18	2.44	0	10
	> 30 yrs.	10	7.60	1.78	3	10
Practice	0–10 yrs.	186	6.87	2.60	0	10	0.16
	11–20 yrs.	125	7.53	2.66	0	10
	21–30 yrs.	39	7.00	2.82	0	10
	> 30 yrs.	10	7.70	2.54	1	10
KAP	0–10 yrs.	186	20.24	5.45	0	29	0.24
	11–20 yrs.	125	20.62	6.31	0	29
	21–30 yrs.	39	20.46	6.72	0	29
	> 30 yrs.	10	22.30	4.86	10	27
Post-test period KAP scores for experience of study participants N = 346
Domains	Experience	N	Mean	SD	Min	Max	p-value
Knowledge	0–10 yrs.	179	7.24	1.48	1	9	0.5
	11–20 yrs.	121	6.92	1.85	0	9
	21–30 yrs.	37	7.05	1.56	2	9
	> 30 yrs.	9	7.56	1.13	5	9
Attitude	0–10 yrs.	179	7.59	1.79	0	10	0.48
	11–20 yrs.	121	7.53	2.32	0	10
	21–30 yrs.	37	7.95	1.65	4	10
	> 30 yrs.	9	8.33	1.41	6	10
Practice	0–10 yrs.	179	7.60	1.98	0	10	0.07
	11–20 yrs.	121	7.45	2.24	0	10
	21–30 yrs.	37	8.30	1.81	4	10
	> 30 yrs.	9	8.56	1.01	6	9
KAP	0–10 yrs.	179	22.42	4.33	1	29	0.31
	11–20 yrs.	121	21.90	5.59	2	29
	21–30 yrs.	37	23.30	4.03	14	29
	> 30 yrs.	9	24.44	2.24	21	28

During the pre and post-test phase, participants with over 30 years of experience were observed to have the highest mean scores across knowledge (mean = 7.00; 7.56), attitude (mean = 7.06; 8.33) and practice (mean = 7.70; 8.56) domains as well as the overall KAP score (mean = 22.30; 24.44) as compared to those participants with fewer years of experience, however the difference was not statistically significant.

Discussion

We assessed the knowledge, attitude and practices among healthcare providers concerning medication reconciliation. Predictors such as educational qualification and years of experience were analysed in relation to knowledge, attitude and practice using multivariable logistic regression. The demographics of our participants demonstrate majority as gender female (68%) and nurse (61%) by profession. This observation is common in relation to other studies performed by Alsulami et al. [29]and Bayazidi et al. [36], which also showed a tendency for nurses and women to be majorly involved. This could be attributed to the presence of nurses at all times in wards unlike pharmacists or physicians, which makes them perform additional roles apart from their traditional duties due to the occasional unavailability or limited number of pharmacists [17]. Also, females in general and nurses have been found to be more optimistic and open-minded towards inter professional learning and co-operation with other professions, which can be the reason behind the increased participation of females and nurses in our study [37].

Our study upholds that MedRec is highly valued by healthcare providers due to its significant role in reducing medication errors and enhancing patient safety. The medication reconciliation process has the ability to recognize medication discrepancies and reduce adverse drug events [38–43].Our findings align with previous work by Al Hasharet al. [17], in which the participants also agreed that medication reconciliation is necessary and that it enhances safety of patients.Participants had adequate knowledge about reporting of medication errors, similar to the findings by Alsulami and colleagues [29].In line with studies from Oman, Kuwait and Jordan, our findings indicate that the majority of participants (86.7% pre-test, 95.4% post-test) were aware of MedRec and deemed it as an invaluable process (pre-test 95.8%, post-test 98%) [17, 18, 44]. However, our findings indicate a lack of well-defined role and responsibilities of each healthcare professional involved in the medication reconciliation process was 14.2% (pre-test) before the educational intervention which has significantly improved after the education intervention to 9% (post-test). We observed that our educational intervention was able to improve the understanding of the participants about their role and responsibilities in the medication reconciliation process (pre-test 71.4%, post-test 85.8%). Regardless of teaching MedRec at universities, further training, particularly for the Best Possible Medical History (BPMH) would be advantageous at both academic settings and workplaces as the MedRec training received at university was found to be inadequate amongst most participants (pre-test 47.8%, post-test 60.7%) [44].

In the present study, most participants used computerized charts (pre-test 64.2%, post-test 68.8%) for documentation of the MedRec process as compared with paper-based forms. Data from the literature supports computerization in facilitating the process of medication reconciliation. Research has shown that implementation of electronic medication reconciliation led to better comprehension of patients regarding their discharge medications and reduced medication discrepancies like omissions, wrong dosage and frequency, wrong drug selection, commissions, or duplications that could occur during admission, transfer and discharge and could potentially lead to adverse events [45, 46].A study demonstrated that MedRec could significantly minimize unanticipated medication discrepancies by 45% by using electronic medication reconciliation [40]. However, this will depend on the user-friendliness of the software and training of its users.

In contrast with the results by AlSulamiet al. [29] in which 57.1% of the participants admits that it was their responsibility to report medication errors, most participants in the present study agreed that it was their responsibility to conduct medication reconciliation (pre-test 75.6%, post-test 84.1%).This suggests that to improve the outcomes from MedRec further, it may be beneficial to create workflows for points of transition in care that explicitly lay out roles and responsibilities, redirect tasks and responsibilities, regulate the MedRec process, and encourage teamwork among healthcare professionals.

The study indicates that healthcare professionals have positive attitudes towards MedRec, which aligns with previous research findings conducted by Al Anazi and colleagues [38], and Aljumah [47]. According to Aljumah [47], concerns about the inadequate resources to ensure the successful implementation of MedRec were expressed by 40% of pharmacists which is similar to the findings of our study in which 35.4% (pre-test) and 37.3% (post-test) of the participants experienced barriers that discouraged them from implementing medication reconciliation services before the intervention.Similarly, Al Hashar and colleagues [17] reported that up to 49% of the participants believed that there were barriers that could impede them or others from practicing medication reconciliation. Examples of such challenges were indicated as lack of funding and time, lack of patient awareness about their medications, unreliable sources for medication history, as well as lack of good communication amongst the healthcare professionals [17].

Our findings align with previous studies in which time constraint was a major barrier to practicing MedRec (pre-test 42.2%, post-test 46%) [17, 37–40].This is supported by the findings of Gionfriddo and colleagues [48] in which almost all of the participants (96%) stated time as a factor influencing the accuracy of medication reconciliation. While medication reconciliation is an important component for delivering good health care, it can be time-consuming, particularly for patients who take multiple medications or are unfamiliar with their regimen. The limitations underscore the need for a re-evaluation of training and reconciliation processes during patient admission and discharge [38]. It can be beneficial to make use of the Electronic Medication Administration Record and Clinical Decision Support System (CDSS) in the medication reconciliation process. The feasibility of incorporating patient-generated data (or PHR) into hospital medical records needs to be investigated. It is also crucial to provide educational resources to patients regarding their medications. However, patients interviewing for clarification, verification, and reconciliation of the medications will still be mandatory [38].

Gionfriddo and colleagues [48] observed that 72% of the prescribing staff was comfortable adding medications to patients’ medication lists and 82% of the staff was comfortable in removing medications. However, in our study, 66.4% (pre-test) and 78.9% (post-test) felt comfortable in adding medications to a patient’s medication order while 54.4% (pre-test) and 65% (post-test) felt comfortable in removing medications from a patient’s medication list during medication reconciliation. These results may indicate unclear criteria to remove medicines from prescription lists and also concerns with removing medicines that were prescribed by different healthcare providers.

Burgess and colleagues [49]observed varying results pertaining to the quality of medication reconciliation with the lowest mean score (1.60) assigned to the reliability of the information provided by the medication history, while the highest mean score (4.36) signified confidence in writing improved medication orders as an outcome of the medication history taken at admission and reconciliation process.On the other hand, most participants in our study agreed that the medication history and reconciliation process provide reliable information (pre-test 85%, post-test 92.5%) and also that it leads to better medication orders being written (pre-test 86.4%, post-test 95.1%).Additionally, most participants in our study believed additional training on medication reconciliation would be beneficial for the participants (pre-test 81.8%, post-test 93.4%) which is in contrast to the findings of Gionfriddo and colleagues [48] in their mixed methods evaluation of the barriers which impact the medication reconciliation process wherein only 37% of the participants agreed or strongly agreed that additional training on medication reconciliation would be beneficial.In addition to highlighting its significance and reiterating the suggested protocols, additional training provided as part of the initial orientation may also serve to define roles, improve comfort levels, and standardize system-wide procedure.

Al Hashar and colleagues [17] reported reconciliation of medications on admission by only 55.6% of the participants, while 43.3% of the participants reconciled medications on transfer to another level of care/unit, and 62% of the participants reconciled medications at the time of discharge.In contrast, the findings of our study were found to be significantly improved with majority of the participants obtaining a best possible medication history from patients when they arrive at their facility (pre-test 76.1%, post-test 85.3%), reconciliation of medications on transfer to another level of care/unit (pre-test 78.3%, post-test 84.7%), and at the time of discharge (pre-test 79.7%, post-test 83.8%).In contrast with the study by AlSulami and colleagues [29], most participants in the present study reported recording errors during medication reconciliation which could cause potential harm (pre-test 74.2%, post-test 73.1%) or did cause actual harm to the patient (pre-test 44.6%, post-test 39.6%).

We aimed to improve the knowledge, attitude and practices concerning medication reconciliation among medical doctors, nurses and pharmacists. Our educational intervention was effective in reaching healthcare professionals at various levels. The educational intervention was successful in improving learners’ knowledge, attitude and practice in every question we tested, and the improvement in the mean response score after the intervention was statistically significant across all the domains. This was in line with the findings of Burgess and colleagues [49] in which a drastic difference was observed in the responses of physicians, nurses, pharmacists, and the healthcare team towards the medication history and reconciliation process in the post-pilot survey with consensus reported in all surveyed categories.

The strength of our study lies in the comparison of mean KAP scores based on the educational qualification and practicing experience of study participants during the pre & post education test period. The participants with a Bachelor’s degree had higher mean knowledge scores while those with Fellowship had higher mean attitude and practice scores. Additionally, the participants with over 30 years of experience were form to have the highest mean scores across knowledge, attitude and practice domains as well as the overall KAP score as compared to those participants with fewer years of experience. This could highlight the importance of additional qualifications as well as greater years of experience in healthcare. This study has some limitations. It was conducted at a single referral hospital and included only 360 healthcare professionals; hence, the study’s findings cannot be universally applied to the entire healthcare population. The recruitment of study participants using convenience sampling could also limit the external validity of the study. Other limitations of the study include the absence of a control group, and reliance on self-reported data to evaluate the KAP.

Further research should be carried out to investigate the impact of similar interventions in multi-centre settings with more participants, along with the future development and deployment of interventions targeted towards system-specific barriers to medication reconciliation. Additionally, future studies need to assess whether the improvement in KAP scores observed in our study remains over time. Based on our findings, a variety of prospective interventions could be developed, such as: patient and staff education programs in order to ensure that they understand medications and the medication reconciliation process; an EHR redesign to enhance usability for entering medications and integration with different sources of data; and different recent technologies and workflows that free up time for employees to perform medication reconciliation.The study suggests that medication reconciliation training must be incorporated into mandatory CME programs for healthcare professionals. The focus of these programs must be on the steps and techniques of medication reconciliation, also providing clear guidelines that can improve collaboration among healthcare professionals for precise and comprehensive medication reconciliation.

Conclusion

The findings of this study indicate that healthcare professionals’ knowledge, attitudes, and practices concerning medication reconciliation were significantly impacted by the educational intervention. Medication reconciliation was more readily comprehended after the educational intervention. Additionally, it showed a favourable impact on attitudes and also demonstrated enhancements in medication reconciliation practices of healthcare providers.A similar educational intervention based on standard international guidelines and adapted according to the local regulations could be used in other hospitals nationally and internationally. These findings have substantial significance for healthcare in general and emphasize the necessity of continued assistance and resources to enhance medication reconciliation practices among health care providers.This study underscores the pivotal role of targeted education in optimizing medication reconciliation, ultimately enhancing patient safety. Therefore, strategic national policies on MedRec training and implementation may truly enhance patient safety.

Abbreviations

MedRec

Medication Reconciliation

KAP

Knowledge, Attitude and Practices

KSH

King Saud Hospital

WHO

World Health Organization

ACA

Activity Accreditation Number

CME

Continues Medical Education

SPSS

Statistical Package for Social Sciences

CVR

Content validation ratio

SD

Standard Deviation

SE

Standard Error

Author contributions

ASMH: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Project administration, Resources, Software, Role/writing- original draft. SMSG: Conceptualization, Project Administration, Supervision, Validation, Visualization, Writing-Review and editing. SASS: Conceptualization, Project administration, Supervision, Validation, Visualization, Writing-review and editing. SMAS: Conceptualization, Funding Acquisition, Supervision, Validation, Software, Writing-Review and editing. SFK: Funding acquisition, Role/writing- original draft, Resources, Writing-Review and editing.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Data availability

Data availability statement: The dataset used for this study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Human Research Ethics Committee (JEPEM), Universiti Sains Malaysia JEPeM Code: USM/JEPeM/PP/24040353 and also from Ministry of Health, General Directorate of Health Affairs, Regional Research Ethics Committee, Qassim region Saudi Arabia with reference number 607/45/5566. All the methods used in the study complied with the relevant guidelines and regulations specified by the ethical committees. At the beginning of the study, scope and purpose of the study were explained related to questionnaire. All participants were provided their informed consent that their participation in our study was voluntary, and they were assured the identity of participants will not be disclosed or revealed, as only anonymized data will be used, and no personal identifiers will be published and all the information obtained in this study will be kept and handled in a confidential manner.

Consent for publication

The authors affirm that consent to publish has been received from all participants should appear in the manuscript.

Competing interests

The authors declare no competing interests.