Objectives: To identify and resolve discrepancies between the medications prescribed when patients are admitted to hospital and the medication usually taken by selected patients, adapting the prescriptions to the pharmacotherapeutic guidelines and the clinical con- dition of the patient.
Method: A prospective study in which patients over the age of 65 with at least one chronic disease in addition to the reason for hospitalisation in the orthopaedic department were selected. Pharmacists reviewed the treatments 24-48 hours after hospitalisation, comparing the order for medication sent to the pharmacy with the clinical history and patient interview. The following data were collected : patient name, age, gender, reason for hospitalisation, comorbidities, drugs, discrepancies, recommendation and acceptance.
Results: During a four-month period, 84 patients were included (23.5% of all the patients admitted to the orthopaedic service), aged 75.40 +/- 10.63 years. 47.6% presented three or more chronic diseases and took 8.14 +/- 2.95 drugs. A total of 120 discrepancies were detected in 60 patients (71.43% of those selected): 71 unjustified discrepancies and 49 justified discrepancies. Among the unjustified discrepancies, the majority were due to the omission of a drug followed by dosing errors, frequency, timetables, route or method of administration. The acceptance of the pharmaceutical recommendation was 88.73%.
Conclusions: The action of the pharmacist, as part of the multidisciplinary team, resolved the discrepancies in the medication on admitting the patients selected.