Background The average hospitalised patient is subject to at least one medicines error per day. More than 40% of medicines errors are believed to result from inadequate medicines reconciliation.

Purpose To investigate the introduction of a medicines reconciliation programme in the orthopaedic surgery unit.

Materials and Methods January 2010–March 2012. The patient selection criteria were ≥65 years old, home treatments ≥5 drugs and anticipated hospital stay ≥3 days. The reconciliation treatment was also performed for any other patients when requested by the doctor. Patients were found to be sensitive to the reconciliation by the pharmacist. Any Drug Related Problems (DRPs) detected were recorded and categorised. A prescription was given with the home treatment, with the aim of continuing treatment, discontinuing it or performing a therapeutic exchange. The process ended with oral and written pharmacotherapeutic information on the day of discharge.

Results Medicines reconciliation was carried out on 300 patients with an average age of 75.86, average stay of 9.57 days and distribution by gender 224 women (75%) and 76 men (25%).The number of medicines/patient was 6.57. During the prescription by the pharmacist, 1058 drugs were provided according to guidelines, 276 were suspended and in 663 cases a therapeutic exchange was performed. As regards the DRPs detected, 50 were caused on admittance and 15 at discharge. The DRPs were classified as follows: safety 51, effectiveness 10, adherence 2 and indication 2. Types of DRP: overdose 17, adverse reaction 4, need of extra treatment 6, unnecessary medicine 23, unsuitable drug 10, insufficient dosing 4, not dispensed 1. As to the seriousness of the DRPs: class 1: 5 patients didn’t use the medicines that they needed; class 2, 24 patients used medicines that they didn’t need; class 3, 23 patients used an erroneously chosen medicine; class 4,10 patients used an erroneously chosen medicine; class 5, 3 patients used a lower dose and/or a different dosage schedule from that required and/or don’t continue treatment for the full duration of the treatment indicated, according to the Granada consensus of 1998.

Conclusions Participation of the pharmacist in the reconciliation of treatment allows DRPs to be detected at admission and discharge and educated the patient on his or her treatment at discharge from the hospital.

No conflict of interest.