Background Medication reconciliation (MR) is necessary to improve the continuity of medication between different levels of care, improving both safety and effectiveness.

Purpose A reconciliation programme was established in a third level hospital. The aim of this programme was to ensure that all necessary chronic medications were prescribed as well as dose, frequency and administration route and that it was suitable for the new clinical situation.

Material and methods Consultations from doctors to the pharmacist service about MR with informatics tool were promoted. The medical services that took part in the project were: traumatology (COT), vascular surgery (VS), respiratory system (RS), digestive surgery (DS) and urology (URO). There were two types of MR: before and after medical prescription. Patients were tagged as frail or not. All patients were interviewed by pharmacists before reconciliation was performed. All pharmaceutical interventions (PI) were collected.

Results 65 patients were included during the first month. Mean age was 69.5 ± 15.11 years (no differences between patients who were frail or not). 508 chronic medications were checked. Mean medications per patient was 7.35 ± 4.49 (frail patients 8.86 ± 4.39 (n = 25), not frail 7.18 ± 7.18 (n = 40)). The hospital services where patients belonged were: COT 25%, RS 25%, ACV 21%, DS 17% and URO 12%. The total number of pharmaceutical interventions was 267. 86% of frail patients needed at least one PI versus only 65% of non-frail patients. The mean number of PI was 3.27 ± 4.2 in frail patients and 4.14 ± 5 in non-frail patients.

When MR was performed before medical prescription (VS and DS), treatments for 100% of patients were adjusted. In the others services, MR was performed after medical prescription. In these cases treatment was modified in 53% of patients.

 Conclusion The pharmacist is necessary and useful in order to improve the quality of pharmacological treatment. Both frail and non-frail patients benefit although more commonly frail patients. MR was more effective when performed before medical prescription.

No conflict of interest.