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5PSQ-118 A medication reconciliation protocol performed by pharmacists: impact on hospital discharge summaries
  1. JJ Arenas Villafranca,
  2. M Moreno Santa Maria,
  3. M Eguiluz Solana,
  4. C López Gómez,
  5. I Muñoz Gómez-Millán,
  6. BTortajada Goitia
  1. Costa del Sol Hospital, Pharmacy and Nutrition, Marbella Málaga, Spain


Background Medication reconciliation (MR) is one of the measures with greater impact on safety in the use of the drug. Reconciliation errors appear frequently in the transitions between the different levels of care, especially at hospital discharge.

Purpose Evaluate the impact of a MR project performed by pharmacists on medical discharge summaries.

Material and methods A protocol was performed to support the MR at discharge by the pharmacy service in a 350-bed hospital and developed over 4 weeks. The pharmacist went to the hospitalisation area from Monday to Friday at the end of the morning and he made the MR prior to discharge. He conducted a structured pharmacotherapeutic interview with the patient to know the home medication prior to admission and later discussed with the physician the new medication that would be added and if there was any modification of the previous medication. A report with active principle, dosage/posology and pharmacotherapeutic recommendations was elaborated. Subsequently, the medical discharge summaries were reviewed and a database was developed in which were included demographic variables (sex, age, no pre-admission drugs) and as a primary endpoint if the physician included in his summary all medication of the patient (complete summary), as well as whether there was any treatment with a finite duration and if this was included in the instructions to the patient. We also selected a sample of discharged patients before the pharmacist’s intervention to compare both groups. Bivariate analysis and logistic regression analysis was used using SPSS software.

Results Twenty-eight patients were recruited in the pre-intervention group and 27 in the post-intervention group: median age (IQR) 65.2 years (50.4–71.6) vs 77.9.(61.1–84.2) (p=0.004), sex 66.7% males vs. 51.7% (p=0.653) respectively. Median number of drugs prior to admission (IQR) was four drugs (0–10) vs eight (5–12) (p=0.028), respectively. Regardless of the age of patients in the post-intervention group, they are about four times more likely to have a complete medical discharge summary (OR: 3.97, 95% CI: 1.18 to 13.3) (p=0.026). The percentages of medical reports with duration specified in the pre- and post-groups were, respectively, 0% vs. 18.5% (p=0.023).

Conclusion The participation of the pharmacist improves the process of MR at discharge, favouring that it is performed in a greater number of patients and that information provided at discharge is more complete.

References and/or Acknowledgements We thank the research team for their support

No conflict of interest

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