Background Detection of drug related problems (DRP) and medication reconciliation (MR) are essential to decrease the harmful effects in patients. If any DRP is found during admission, it is important to notify not only the professional responsible but also the general practitioner (GP).

Purpose To identify and notify DRP and discrepancies between chronic treatment and hospital medications when patients are admitted to the traumatology department (TD) in a hospital with 400 beds.

Material and methods Patients over the age of 65 years admitted to the TD with 5 or more chronic medications were included. Pharmacists reviewed the treatment 24 hours after hospitalisation, to perform MR, taking into consideration the patient’s interview and clinical history. Moreover, the patient’s medical prescription and analytical parameters were reviewed every day. If any DRP or any change in medication was found during admission, patients and their GPs were informed.

Results Between November 2015 and July 2016, 241 pharmaceutical recommendations (PR) were registered, corresponding to 230 patients. 60% were accepted, 13.4% were justified discrepancies and 26.6% were not accepted. From the 241 PR, 80.8% were discrepancies between usual medication and medication on hospitalisation and 19.2% were DRP (inappropriate medications in patients with Parkinson’s disease and elderly patients, dose adjustment in patients with renal insufficiency, interactions, sequential therapy and adequacy of treatment). From the MR discrepancies, more than half (52.2%) were related to omission of medication, 29.6% were discrepancies found with the dose prescribed and 18.6% were related to medication prescribed at admission time that patients were not taking any more. During this period of time, 18 GPs were informed about detected DRP and changes in medication during hospital admission.

Conclusion Pharmacists integration in multidisciplinary teams can help to detect and resolve discrepancies between chronic treatment and hospital medications and minimise DRP. It is essential to update GPs if any discrepancies or changes in medication have been found during healthcare transition.

No conflict of interest