Background Medication reconciliation and pharmacotherapeutic review reduces drug-related problems and improves patient safety. It promotes compliance and contributes to the prevention of errors, by systematically analysing patient’s medication and detecting discrepancies. Discrepancy is defined as the difference between the patient’s usual medication and the one that is prescribed at each moment of care transition.

Purpose Characterisation of the medication reconciliation and pharmacotherapeutic review performed by the clinical pharmacist at the orthogeriatric unit of a central hospital over a 12 month period.

Material and methods Retrospective, observational study conducted from January to December 2017. Medication reconciliation and pharmaceutical review were performed at the hospitalised patient’s admission to the orthogeriatric unit. The Beers and STOPP/START criteria were used to evaluate potentially inappropriate medications in older people. Pharmaceutical intervention was performed when the discrepancies were not according to the bibliography, and their acceptance by the clinical team was evaluated. Data was recorded and treated in Excel version 15.3.3.

Results Thirty-one patients were included with a median age of 83 years. Of those, 68% were female. A total of 249 drugs were analysed (7.7/patient) and 146 discrepancies identified (4.7 discrepancy/patient). The most common discrepancy was ‘omission’ (n=120; 82%). The pharmacotherapeutic group with the greatest number of discrepancies was the ‘cardiovascular system’ (n=35; 30%) and the largest number of interventions (29%) was also in this group. A total of 80 interventions were performed and the most frequent was ‘drug introduction’ (59%). The pharmaceutical interventions acceptance level was 78%.

Conclusion Medication reconciliation and pharmacotherapeutic review in the orthogeriatric unit improved pharmaceutical and physician communication and cooperation, allowing the optimisation of this patient’s therapy.

Reference and/or acknowledgements Elizabeth A, Janne K, et al. Medication reconciliation of patients with hip fracture by clinical pharmacists.

No conflict of interest.