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4CPS-238 Management of a medication reconciliation plan at admission in different levels of geriatric healthcare
  1. M Hernandez1,
  2. C Mestres2,
  3. P Amoros1,
  4. A Agusti1,
  5. L Puerta1,
  6. B Llagostera1
  1. 1Grup Mutuam, Pharmacy, Barcelona, Spain
  2. 2University Ramon Llull, School of Health Sciences Blanquerna, Barcelona, Spain


Background Medication reconciliation (MR) and review reduce drug-related problems (DRP) and improve patient safety. The elderly population is at risk of DRP during transitions through different levels of healthcare. Pharmacists giving pharmaceutical care in long-term facilities could detect this problem and improve treatment quality and patient safety.

Purpose Detect and classify DRP in long-term care institutions and evaluate the impact of clinical interventions in quality prescription in order to improve patient safety. Give pharmaceutical care focused on the person by detecting and quantifying the DRP and evaluate the impact of the interventions.

Material and methods Prospective study conducted in intermediate care hospitals and long-term care institutions (336 beds).

All treatments were reviewed at patient admission (all patients included). DRP were detected and taken into account was the actual prescription, previous discharge reports and controls, and medical history. The DRP were classified by the American Society of Health-System Pharmacists (ASHP).1

Problems and discrepancies were notified to the clinician during the first 48 hours after patient admission.

The impact of the interventions in prescription quality was evaluated through the Medication Appropriateness Index (MAI).2

All interventions were managed by PowerPivot® software.

Results Study period July 2016 to August 2017, 1832 patients were reviewed. Mean age 81 (105–39 years-old), 60% females. Average drugs per patient 8.85±4.03. In 880 patients, 1370 interventions were conducted (952 patients no problem was found).

  • DRP: 1,074 (82%). Most frequent: omissions 16%, inappropriate drugs (13%) and schedule (10%).

  • Medication errors: 240 (18%).

Degree of acceptance of pharmaceutical interventions 75%.

Impact of interventions accepted, MAI scores per drug, improved from 2.99 to 0.95 (p<0,0001) post-intervention.

Conclusion Patients are at risk of DRP at the moment of admission in long-term care facilities. Treatment revision improves the quality of the prescriptions and guarantees continuous healthcare assistance.

Although more research is needed, pharmaceutical care in intermediate care hospitals and long-term care institutions enables the optimisation of pharmacotherapy after an acute episode, taking into account the new patient’s requirements and focusing on patient-centred care.

References and/or Acknowledgements 1. Van Mil JF. Drug-related problem classification systems. Ann Pharmacother2004;38(5):859–67.

2. Hanlon, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol1992;45(10):1045–51.

No conflict of interest

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