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4CPS-209 A clinical pharmacist-led medication reconciliation service in geriatric patients upon admission to hospital
  1. E Vella Seychell1,
  2. A Weidmann2
  1. 1The Rehabilitation Hospital Karin Grech, Department of Pharmacy, Pieta’, Malta
  2. 2Robert Gordon University, School of Pharmacy and Life Sciences, Aberdeen, UK


Background At the points of admission and discharge from hospital, patient or medication-related factors such as older age and an increased number of drugs can lead to medication errors.1 In 2006, the World Health Organisation initiated the High 5 s Project where it recommended medication reconciliation to prevent medication errors at transition points.2

Purpose To implement and evaluate a clinical pharmacist-led medication reconciliation service in geriatric patients upon admission to hospital, in terms of frequency, type and potential severity of the medication errors identified.

Material and methods Medication reconciliation interviews were conducted to record the best possible list of all the medications a patient was taking upon admission to hospital. This list was then compared with the drug history initially recorded by the physician. Any discrepancies were considered as medication errors. Errors were categorised by type and therapeutic group. An expert panel rated each medication error for its potential severity. A secondary outcome included studying the relationship between the number of errors and patient demographics or medication-related factors.

Results A total of 154 patients were eligible for inclusion; 136 (88.31%) patients had at least one error. Four hundred and ninety-eight medication errors (mean of 3.23 errors per patient) were determined with the most common type being that of drug omission (n=252, 50.6%). The therapeutic group with the highest number of errors was that of the alimentary tract and metabolism (n=132, 26.51%). With regards to severity, 208 (41.77%) of the medication errors potentially required monitoring or intervention to prevent harm while 33 (6.63%) had the potential to cause harm. Medication errors were found to be correlated with the number of drugs at admission and total sources of information (p<0.05).

Conclusion A clinical pharmacist-led medication reconciliation was an effective procedure to identify and resolve medication errors. Results obtained formed the basis for the development of such a service to optimise patient care and safety.

References and/or Acknowledgements 1. Salanitro AH, et al. Effect of patient- and medication-related factors on inpatient medication reconciliation errors. J Gen Intl Med2012;27(8):924–32.

2. Joint Commission International(JCI). Projects supporting our mission[online] 2017. USA: Joint Commission International. Available from: http://www. jointcommissioninternational. org/about-jci/projects-supporting-our-mission/(Accessed: 10 October 2017).

No conflict of interest

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