Background Medication reconciliation (MR) is known to minimise medicine errors and reduce morbidity in hospitalised patients. This process aims to identify and solve unintended medicine discrepancies, defined as differences between the home treatment prescription and the first hospital prescription.

Purpose To asses the number, type and importance of pharmaceutical interventions related to MR in surgical patients.

Material and methods Prospective study conducted in services of traumatology, general surgery and urology of a tertiary level hospital from January to May 2015. All patients admitted to surgical wards who were ≥65 years old were included.

The methodology used in the MR process was as follows: within 24 h of the patient’s admission, the pharmacist obtained the pre-admission chronic treatment by interviewing the patient or the patient’s family/caregiver, or from the patient’s medical chart and primary care records. This was compared with the treatment prescribed in hospital. All of the discrepancies detected (dose, regimen, route of administration or omission) were discussed with the attending physician to determine whether it was intended in accordance with the patient’s condition. If the discrepancy was unintended, appropriate changes were made to the medicines.

Results 628 patients (37.10% general surgery, 43.63% traumatology, 19.27% urology) were included, with a mean age of 74.55 years. We found 2857 discrepancies between home and hospital treatment; 55 were intended and 2802 were unintended. Unintended discrepancies were classified as: omission of medication=2702 (96.4%), different dosage/route of administration/regimen=71 (2.5%), different medication=15 (0.54%), not indicated medication=13 (0.46%) and duplicate = 1 (0,036%). The average discrepances per patient was higher in general surgery (5.27) than urology (5.25) or traumatology (4.09).

Conclusion The high number of detected unintended discrepancies justifies completion of a process of MR in patients admitted to the services of traumatology, general surgery and urology. The highest percentage of unintended discrepancies corresponded to omissions of medications. Therefore, the presence of a pharmacist in surgical services is key to ensuring that patients receive their home medication during the transition between different levels of care.

References and/or Acknowledgements

1. Rogers G, Alper E, Brunelle D, et al. Reconciling medications at admission: safe practice recommendations and implementation strategies. Jt Comm J Qual Patient Saf 2006;32:37-50

References and/or AcknowledgementsNo conflict of interest.