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Medication discrepancies revealed by medication reconciliation and their potential short-term and long-term effects: a Norwegian multicentre study carried out on internal medicine wards
  1. Niklas Nilsson1,2,
  2. Marianne Lea1,2,
  3. Yvonne Lao1,2,
  4. Katherine Wendelbo2,3,
  5. Gløer Gløersen2,4,
  6. Morten Mowé5,6,
  7. Hege Salvesen Blix2,7,
  8. Kirsten K Viktil2,8
  1. 1Department of Pharmaceutical Services, Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, Oslo, Norway
  2. 2School of Pharmacy, University of Oslo, Blindern, Oslo, Norway
  3. 3Levanger Hospital Pharmacy, Central Norway Hospital Pharmacy Trust, Levanger, Norway
  4. 4Hospital Pharmacy Tønsberg, Hospital Pharmacies Enterprise, Tønsberg, Norway
  5. 5Department of General Internal Medicine, Oslo University Hospital, Oslo, Norway
  6. 6Institute of Clinical Medicine, University of Oslo, Blindern, Oslo, Norway
  7. 7Department of Pharmacoepidemiology, Norwegian Institute of Public Health, Oslo, Norway
  8. 8Diakonhjemmet Hospital Pharmacy, Oslo, Norway
  1. Correspondence to Niklas Nilsson, Department of Pharmaceutical Services, Oslo Hospital Pharmacy, Kirkeveien 166, Oslo 0450, Norway; niklas.nilsson{at}


Purpose To investigate the extent of medication discrepancies (MDs) revealed by medication reconciliation (MR) and to assess the potential clinical relevance of the MDs for the patients in a short-term and long-term perspectives.

Methods Patients ≥18 years admitted to five internal medicine wards were included in this prospective study. MDs between the medication list obtained by physicians at hospital admission and medication list obtained by a structured MR process by pharmacists were identified and assessed for clinical relevance by an expert team. Clinical relevance was assessed in two ways as (a) if they were not acted upon during the hospital stay (short term) or (b) if they persisted after discharge from the hospital (long term).

Results In total 262 patients, age 19–98 (SD 18.94, mean 73.4 years), 58.8% female, were included. 79.4% of the patients had at least one MD with a mean of 3.2 MDs/patient. 80.7% of the MDs were discussed with the physician, and 95.5% of these were acted upon. Of the 438 MDs evaluated by the expert panel, 35.2% and 71.2% were assessed to be of moderate, major or extreme clinical relevance in the short-term and long-term perspectives, respectively.

Conclusions By using a structured approach, MDs were identified for 80% of the patients and the majority of the MDs were evaluated to possibly harm the patient in a long-term perspective. The results emphasise that structured MRs may improve patient safety.

Trial registration number 2011/542.


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