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General and Risk Management, Patient Safety (including: medication errors, quality control)
Medication reconciliation during assistencial transitions in institutionalised older patients
  1. M.J. Mauriz Montero,
  2. M.T. Rabuñal Alvarez,
  3. M.I. Martín Herranz
  1. 1Complexo Hospitalario Universitario A Coruña, Servicio de Farmacia, A Coruña, Spain


Background Older patients in nursing homes often have comorbidities that might derive in medical consultations and hospital admissions with changes in their treatment.

Purpose To describe a program of medication reconciliation during assistencial transitions, between specialised and primary care, in a nursing home.

Materials and methods Prospective study of new admissions and assistencial transitions in a geriatric residence of 172 patients between April 2010 and April 2011, by means of the review of the pharmacotherapeutic profile of the nursing home patients'. Data collected: demographics, diagnoses, treatments and analytical data. Data extraction: electronic clinical history of specialised and primary care (IANUS, SIFAR), program of dispensation to inpatients and outpatients (SINFHOS, DIPEX), reports of discharges and consultations of private health centres and reports of the emergency department.

Results 204 patients were included. Pharmacotherapeutic profile was performed and/or updated after each assistential transition (32 admissions in residence, 50 discharges, 63 consultations in specialised care and 7 in emergency department). 79% of these originated discrepancies. In 83 patients (41%) at least one discrepancy was detected. Median age and sex of patients with discrepancies: 81, 5±9,3 years, 53 women. The number of discrepancies detected was 170: 62 in the residence's admission from primary care, 54 after discharges, 50 after consultation in specialised care and 4 were generated from emergency department. 100% of discrepancies were corrected after pharmacist's intervention. Distribution of discrepancies was as follow: 38 therapeutic alternative for adaptation to the pharmacotherapeutic guide, 29 forgotten drugs, 25 deletion of drug from therapy, 20 adjust/change of treatment, 11 end of treatment to the discharge, 8 therapeutic drug monitoring, 9 duration of treatment, 5 duplicated drugs, 3 frequency adjustment, 3 stream lining of antibiotics, 1 wrong drug and 18 other discrepancies.

Conclusions Our program of reconciliation shows that a high percentage of the discrepancies concern to the efficacy and the safety of the patient.

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