Background Aging of the Spanish population increases the elderly patient consensus and demand for health care in hospitals. Elderly patients have particular characteristics that increase the risk of medication errors.

Purpose To establish a programme that involved medicines reconciliation and adapted drug information for elderly patients with polypharmacy at discharge. Several electronic resources were used in order to promote continuity of care and adherence to pharmacotherapy.

Materials and Methods Geriatricians selected patients according to three criteria: more than 70 years old, at least five medicines at discharge and some difficulty understanding them. Doctors electronically requested the Pharmacy Department to complete the developed ‘Medication Information Form at Discharge.’ A pharmacist reviewed the treatment prescribed at discharge and reconciled it with the patient’s medicines during hospitalisation via electronic records. The pharmacist resolved discrepancies found with the physician. A visually appealing and understandable form was submitted electronically to be given to the patient.

Results From April 2011 to March 2012, this service was performed for 57 patients. Most of them were women (77.2%) with a mean age of 88.5 (SD 6.2) years old. 555 Drugs were reported (9.7 drugs/patient) and 696 were reconciled (12.2 drugs/patient). 143 discrepancies were found (2.5 discrepancies/patient): 135 of them were justified (94.4%) and the other 8 were medicines errors (0.014%).

Conclusions Information technology enables pharmacists to undertake this work: improving communication between professionals, inserting the ‘Medication Information Form at Discharge’ into clinical documentation, enabling medicines reconciliation and adapting the information sheet to the geriatric population. This practise provides reconciliation of medicines that have been prescribed before, during and after hospitalisation. In summary, it is necessary to achieve adequate therapeutic adherence and to avoid administration errors, which may have consequences on patient health and increased costs.

No conflict of interest.