Background Hospital/home treatment reconciliation often finds a lack of concordance between how patients take their medicines and how they should take them.

Purpose To reveal which drugs patients take and are not included in our clinical information sources (medical income report and electronic primary care history) and which drugs patients do not take but are recorded in these sources. All of them were detected by a pharmacist-patient interview.

Material and methods For two months a hospital pharmacist carried out treatment reconciliation at admission. Home treatment information from the two clinical information sources was recorded, and then a medicines interview was conducted. A report was written reflecting the real use of medicines in every case. All omitted or overprescribed drugs were recorded for statistical analysis.

Results 23 patients were interviewed, 73.6 ± 11.6 years, with a median of 9 drugs in their home treatment (range 5 to 20), 63.6% women. We found that 25.9% of patients had medicine (s) omitted from their medical admission reports, and 17.8% from their electronic primary care history. A total of 83 drugs were omitted in the physician admission reports. These included some high-risk drugs: 3 patients taking digoxin, 3 antiplatelet drugs and 2 anticoagulants. 36 drugs were omitted in the primary care electronic clinical history, including 2 omissions of anticoagulants and 2 antiplatelet agents. Regarding medicines that the patient did not take but were stated in the information sources: the physician admission report overprescribed 30 drugs, including 1 antiplatelet drug, 1 antipsychotic and 1 antidepressant (high-risk drugs). With respect to the electronic clinical history, 24 drugs were overprescribed, including the high-risk drugs 1 antiplatelet drug, 2 antipsychotics and 2 antidepressants.

Conclusion The quality of the data provided by the information sources is not sufficient, creating a risk of drugs omission or over-prescription. Hospital pharmacists could contribute positively to medicines reconciliation at admission.

Reference

1. Galvin M, Jago-Byrne MC, Fitzsimons M, et al. Clinical pharmacist’s contribution to medication reconciliation on admission to hospital in Ireland. Int J Clin Pharm 2013;35:14–21

ReferenceNo conflict of interest.