Background Risk of medicines discrepancies is high during care transitions where treatment changes are frequent.

According to the Institute for Healthcare Improvement, medicines reconciliation is the formal process of obtaining a complete list of the patient’s prior medicines and comparing it with what has been prescribed on admission, care transitions or hospital discharge. Changes should be documented and communicated properly to the follow-up physician and patient or caregiver.

Purpose To determine the drug discrepancies at hospital discharge of complex chronic patients.

Material and methods Cross-sectional study over 6 weeks in a secondary hospital to investigate the prevalence of reconciliation discrepancies of complex chronic patients. The criteria for consideration as a complex chronic patient included: 2 hospitalizations with minimum 9 days length of stay and a chronic disease. We excluded patients whose destination was a nursing home, healthcare centre or home care plus a support program. A pharmacist reviewed a report of all the complex patients’ chronic medicines at discharge and compared them with treatment prescribed in the electronic prescription and medicines prior to regular admission,

Results We reviewed all complex chronic patients who were discharged from July 15th 2014 to August 31st 2014 (n = 103) and we included 92 patients. Mean age was 78.5 years and 58.3% were men. 63% of patients had a discrepancy between the information in the discharge report and electronic prescriptions given to the patient. Overall we found 1.3 discrepancy rate per patient. The highest percentage of discrepancies occurred by omission (49.2%), followed by incorrect frequency (29%), dosing errors (19%) and others (3%)

Conclusion Unjustified medicines discrepancies between discharge report and electronic prescription are frequent. This can lead to medication errors or doubts about the correct overall treatment. A multidisciplinary team: doctor, pharmacist and nurse could prevent a high percentage of these discrepancies with a final review of the medicines prescribed at discharge. Furthermore, it is important to explain the medication plan to the patient or caregiver.

References and/or acknowledgements No conflict of interest.