Background Since January 2011, pharmacists have been taking medication histories (MHs) both in abdominal and orthopaedic surgery wards. Out of 1400 annual MHs, 40% are for patients whose intervention is planned. During the pre-anaesthesia consultation, the anaesthetics form (AF) is filled out and currently used as reference for post-operative prescriptions.

Purpose The objective was to assess the concordance between the MH and the AF data in order to find ways of improvement.

Materials and Methods A five-week prospective study was conducted by two experienced pharmacy students (>100 MHs done by each one). During the medicines reconciliation, the discrepancies were split into two groups: medicines (inappropriate drug, missing or additional medicine, incorrect or omitted dosage) and administration plan (omitted, incorrect or incomplete).

Results 70 patients, involving 272 medicines according to the MH and 223 according to the AF, were included in the survey. Discrepancies were found in 73% of patients. These patients were significantly older and were taking more medicines than the ones without any discordance (60.5 years versus 47.5; 5.3 medicines/patient versus 1.7). Among the discordances, 44.9% (n = 122) were due to ‘medicines errors’ with the following breakdown: missing medicine 45% of cases, omitted dosage 38%, medication discontinued 13%, incorrect dose 2%, wrong drug 2%. Regarding the discordances linked to the ‘administration plan’, the plan was omitted, incomplete or incorrect in 47%, 40%, or 13% of cases, respectively.

Conclusions This demonstrates that the pharmaceutical consultation including MH is mandatory and when done prior to admission can greatly improve the post-operative prescription process. The final step to be done with other healthcare professionals involved (anaesthetists, surgeons, nurses, pharmacy technicians, pharmacists), is to identify the best time to schedule MHs in the whole process.

No conflict of interest.