Background Medication reconciliation (MR) has been recognised as an important approach to improve the quality use of medicines by reducing the burden of medication discrepancies at care transitions.

Purpose To evaluate the harmony between the most complete and accurate list of a patient’s current medications (PCM) and the list in the medical report at admission to, and at discharge from, the hospital.

To identify/analyse the discrepancies found after the MR realised by the pharmacist.

Material and methods Prospective study (23 December 2016 to 23 April 2017). Target population: patients≥65 year-old and >5 medications as PCM, admitted in internal medicine service (second-level hospital).

At admission the pharmacist carried out: interview to patient/guardian, review of clinical history, review of the PCM list registered in the report and MR. The complete and accurate PCM list was registered in the clinical history at admission and at discharge.

Medication discrepancies were analysed comparing PCM’s list registered by the physician (at admission/discharge), with the list obtained by the pharmacist, after MR. They were classified according to the ATC classification.

Discrepancy definition any difference between the information obtained by the pharmacist and the registered one in the medical report. Classification: commission, different dose/route/frequency/form, duplicity, wrong medicine, omission, and unfinished prescription/clarification.

Results Patients analysed: 106 (51.9% males; median age: 83.7 years old). In 17 patients, CM was only checked at admission.

Median medicines number: 9.2/patient (at admission and discharge). Total detected discrepancies number: 578 (median: 5.4/patient; (range: 0–14)).

Admission: three patients presented no medication discrepancies in the medical report. Detected discrepancies (n=527): incomplete prescription (63.6%), omission (15.7%), other discrepancies (20.7%). Discrepancies solved: 62.2%.

Discharge: 51 patients presented no medication discrepancies in the medical report. New discrepancies detected (n=51): incomplete prescription (66.7%), omission (23.5%), other discrepancies (9.8%). Discrepancies solved: 17.6%.

Main ATC group with some discrepancy: cardiovascular system (31.7%), nervous system (18.3%).

Conclusion Harmony was found between PCM’s list registered at admission and the real medication list only in 2.8% of patients, which improved notably after the MR by the pharmacist: 57.3% had no medication discrepancies at discharge. This helps in a correct transmission of information in future care transitions.

63.1% of the discrepancies were incomplete prescriptions.

Cardiovascular and nervous system were the main medicines groups with discrepancies.

Reference and/or Acknowledgements 1. Rose AJ, et al. Beyond medication reconciliation: the correct medication list. JAMA2017May 23;317(20):2057–2058.

No conflict of interest