Background At admission and discharge to/from hospital information concerning the correct medicines has to be transferred between health professionals. If this information is incomplete or lost, the correct medicines for patients are at risk. We therefore analysed adverse events at the in-/out-patient interface in order to optimise the medical treatment of patients at these critical steps.

Purpose To optimise the medical treatment of patients at admission and discharge to/from hospital.

Materials and Methods The prescription and resulting administration of medicines of all patients who underwent spinal stabilisation surgery in our clinic in the year of 2011 were recorded retrospectively. We analysed the resulting dataset in terms of frequency and severity of medicines errors.

Results 147 datasets were included, while only 144 of these contained complete information concerning post-discharge medicines.

The medicines taken before admission to the hospital were not documented correctly in 16% of the admission reports. Complete transfer of the previously taken medicines to drugs listed by the hospital pharmacy was missing in 72%. Both these factors frequently led to incomplete continuation of the medicines taken previously (before admission). Uncertainty concerning the listed drugs [the medicines prescribed for use in hospital] was identified as the main reason for this problem.

At discharge the prescribed medicines did not match the medicines taken before admission in 78%. An indication for this change was however only documented in 9%.

Missing documentation of the medicines taken before admission and an unconsidered transposition of the drugs listed in the hospital pharmacy to the discharge information were identified as the most common risk factors.

Furthermore in 37% (n = 41 who received anticoagulation treatment) and in 67% (n = 9 who received metformin) these treatments, which were paused preoperatively, were not resumed postoperatively.

So in order to optimise treatment at the in-/out-patient interface a number of processes were modified:

• At admission – the medicines history is now taken by a clinical pharmacist, who was employed for this purpose instead of a physician. The pharmacist is informed via the hospital administration software (SAP) or the admissions management system when a new patient is admitted.

• The hospital pharmacist transfers previously taken medicines to the listed drugs.

• A new admission sheet was designed standardising the recording of medicines history and transfer to listed drugs. This sheet provides all the necessary information concerning the drugs taken previously to physicians and nurses in a standardised form throughout hospitalisation and when composing the discharge information.

These measures allow continuous administration of the medicines taken before admission over the in-/out-patient interfaces and re-administration after the perioperative period of suspended drugs like anticoagulants and metformin. The clinical pharmacist furthermore cheques the medicines in stock of each unit of the clinic and orders any new or special drugs form the hospital pharmacy. During hospitalisation the physicians consult the clinical pharmacist on specific medicines issues.

Conclusions In order to achieve a high level of medicines safety physicians, nurses and clinical pharmacists have to cooperate closely and frequently. Each step in the medicines process should be performed by the specialist most suited for this task. The medicines process has to be standardised and transparent, so that each group involved (nurses, physicians, clinical pharmacists) knows at any time where to find the required information. In order to achieve this, the neurosurgical department now employs our ‘own’ clinical pharmacist. A final review of the measures taken and the overall quality of medicines at the in-/out-clinic interface is scheduled for 2013.

No conflict of interest.