Background Transitions in care put the patients at risk for medication error as a result of poor communication and information loss. Medication reconciliation (MR) was conducted to record the best possible list of all the medications patients were taking upon admission. Reconciliation errors are an important cause of morbidity and have a predominant role in hospitalised patients, specifically in chronic complex patients (CCP).

Purpose To assess a programme of MR at admission and at discharge implemented in a CCP and their degree of acceptance by the physician.

Material and methods A prospective study was made from January to June 2018. All patients that at admission to hospital were classified as CCP were included (palliative patients were excluded). At admission to the hospital, the pharmacist carried out an interview with the patient/guardian, review of clinical history and the patient’s current medication list (PCM).

This complete and accurate list was registered in the clinical history and compared with the PCM registered by the physician. Medication discrepancies were analysed and communicated.

A registry was made of all the unjustified discrepancies detected, reconciliation errors, pharmaceutical interventions carried out, type and acceptance. At the time of discharge, the reconciliation report was made consisting of the following information: current treatment of the patient at discharge, interactions and recommendations for the patient.

Results A total of 66 patients’ CCP were admitted (51.5% female and 48.5% male), mean age 84.9 years (±5.9 SD). Fifty-five (84%) patients were reconciliated at admission. The mean number of medication lines were 10.7. The following were detected: 54 unjustified discrepancies,and 0.98 medication error/patient (46 omissions, four contraindicated medications, two different doses, one wrong medication and one start medication not prescribed), of which 45 were accepted (83%). At discharge, 41 reports were made (62.1%) and 32 interactions were detected. The rest of the reports at discharge were not carried out due to: 12 (18.2%) were exitus during admission and 13 (19.7%) for other reasons.

Conclusion A pharmacist MR is an effective procedure in identifying and resolving medication errors. The degree of acceptance of pharmacists’ interventions by the prescriber was high. Detection of the omission of chronic treatments was the most frequent pharmacists’ interventions recorded.

References and/or acknowledgements None.

No conflict of interest.