Background Polypharmacy, common in the elderly, is an important risk factor for drug-related problems. In this context, the hospital pharmacist can contribute to supporting clinicians in promoting the safe use of medicines.

Purpose To identify the need for an appropriate medicines reconciliation system in a sample of hospitalised elderly patients.

Material and methods Medical records of patients ≥65 years taking ≥5 drugs admitted during a one-month period to 5 general medicine and geriatric wards were retrospectively reviewed. The following data were collected by a hospital pharmacist: number of drugs prescribed, dose omission, frequency, administration route, pharmaceutical form and potential drug-drug interactions.

Results We analysed the medical records of 75 patients (36 men, 39 women, mean age 81 years). Overall, patients were admitted with 634 drugs used at home; in the first 24 h after admission and at discharge, 723 and 645 drugs were prescribed, respectively. At the recognition stage, the dosage form was omitted in 17% of prescriptions, the dose in 12%, route of administration in 20%, frequency in 26%.

At discharge rates of omission decreased to 2% for dosage form, 2% for route of administration, 7% frequency.

Overall, 816 potential drug-drug interactions were identified. In 13 medical records medicines were not prescribed in accordance with the hospital formulary; allergies/intolerances were not taken into account in 2 discharge letters and in 2 inpatient prescriptions, while 9 suspected adverse drug reactions were not notified.

Conclusion The review of the actual process of accuracy of drug recording in the patient’s medical record highlights the need for a more structured procedure. An active role for hospital pharmacists is foreseen, in order to ensure the safe use of medicines.

References and/or acknowledgements No conflict of interest.