Background Medicines reconciliation and medicines reviews by hospital pharmacists can reduce drug-related problems in older people during care transitions.

Purpose To evaluate the incidence of reconciliation and medicines errors, as well as acceptance rate of recommendations made by pharmacists at the admission process of elderly polymedicated patients at the Emergency Department of an acute care tertiary hospital.

Materials and methods For one month (September 2013) the authors reviewed the electronic prescriptions of patients over 75 years of age coming from nursing homes with more than five prescribed drugs upon admission, and compared it with the medicines record provided by their nursing homes. Undocumented discrepancies and medicines errors were recorded and, when necessary, correct usual treatment and pharmacists’ recommendations were placed on the electronic clinical record system. Follow-up of the interventions was made during patients’ hospitalisation.

Results 64 patients were reconciled (mean age 85.7, 43.8% women), with an average of 10.9 chronic drugs per patient. 68.8% belonged to Internal Medicine (IM), 15.6% Traumatology, 6.3% Pneumology, 4.7% Gastroenterology, 1.6% Neurosurgery, 1.6% General Surgery and 1.6% Cardiology. 47 undocumented discrepancies (51.1% different dose/frequency, 27.7% omission, 10.6% presentation, 8.5% addition of a drug that the patient was not previously taking and 2.1% duplication) and 6 medicines errors were identified (66.7% untreated medical conditions, 16.7% contraindications and 16.7% STOPP/START criteria). 52 recommendations were made (0.8 per patient) and 36 of these (69.2%) were accepted by the physician.

Conclusions The pharmacist-driven medicines reconciliation and medicines review programme led to the detection of numerous undocumented discrepancies and medicines errors. The most frequent type of discrepancy was difference in dose or frequency and the main medicines error was the lack of treatment of a medical condition. The majority of the recommendations related to these discrepancies and medicines errors were accepted, reinforcing the role of the pharmacist in this task.

No conflict of interest.