Background Medicines reconciliation may be effective in reducing clinically important medicines errors among high-risk patients such as elderly polymedicated people.

Purpose To standardise a home medicines reconciliation process in frail elderly people admitted to hospital.

Materials and Methods In this two-month pilot study in a 280-bed hospital, a reconciliation process was designed by a multidisciplinary team. Geriatricians obtained medical information to verify home medicines by interviewing patients with the help of nurses and also from other medical reports. Pharmacists were informed of these patients by the electronic records thus made by geriatricians. Pharmacists checked their medical records with the currently prescribed medicines and identified all discrepancies revealed in reconciliation, and if appropriate, notified attending physicians.

Results A total of 45 patients were included in the study with a median age of 87.8 (SD 4.6) years and a median of 8 (SD 3) current home medicines. The pharmacist was consulted in 86.7% of patients. Pharmacists reviewed all these patients and discrepancies were detected in 41% patients: a) prescription of a drug not included in the hospital formulary (23.1% of patients). The substitution of these drugs proposed by pharmacists was accepted by physicians in 44.4% patients. b) Other kinds of discrepancies were detected in 5 patients (12.8%). The degree of acceptance of these pharmaceutical interventions was positive in just one patient. The rest was either negative or not assessed by physicians. 100% of discharged patients included in their medical report a list of active drugs and also, specific recommendations were made about interrupting former medicines.

Conclusions Medicines reconciliation developed by a multidisciplinary team has been found to be useful in detecting and reducing discrepancies with home medicines when frail elderly patients are admitted to hospital. It will be interesting to implement the same process, involving a pharmacist, when patients are discharged.

No conflict of interest.