Background Internationally, clinical pharmacy services in oncology are usually patient-oriented and often include medication reconciliations and reviews. There is a need to find out how clinical pharmacists can improve medication safety in the division of solid tumours of Helsinki University Central Cancer Centre.
Purpose The aim of this study was to find out the accuracy of the medication charts and identify drug-related problems (DRPs) among over 65-year-old patients using six or more medicines in the urological-oncological outpatient clinic.
Materials and methods When the patient arrived at the urology-oncology outpatient clinic, the accuracy of the medication charts was assessed by pharmacist-led medication reconciliation, including patient interview. Information concerning patient’s medication was also searched for from the national electronical prescription centre and from the records of previous hospital visits. DRPs, such as drug-drug interactions, adverse drug reactions and overlapping medications, were identified with the pharmacist-led medication review. Pharmacists discussed the clinical relevance of DRPs with the oncology specialist.
Results Altogether, 100 patients with urological cancer were included in this study. On average, they were 73 years’ old and used 12 medications. On average, there were six discrepancies per patient in the hospital medication chart. Only two patients had a correct medication chart. The discrepancies were most commonly related to paracetamol (n=38), pantoprazole (n=29) and metoclopramide (n=19). The most common discrepancies of high-alert medications were related to oxycodone (n=17), the combination of paracetamol and codeine (n=10), and enoxaparin (n=10). In the medication review process, 139 DRPs were identified with 70 patients (two per patient). Of these DRPs, 70% were regarded as clinically relevant and lead to actions by the oncology specialist. Reconsidering the need or efficacy of the medication (39%) or medication adjustment due to renal insufficiency (17%) were most commonly identified with medication reviews. DRPs were usually related to non-oncological medications such as pantoprazole (n=19), the combination of calcium and vitamin-D (n=9), and codeine (n=7).
Conclusions The medication reconciliation process should be developed in the urology-oncology outpatient clinic. Multiprofessional medication reviews can be used to detect and resolve DRPs of older patients with urological cancer. The results of this study can be exploited when clinical pharmacy services are created and developed in the University Central Cancer Centre.
References and/or acknowledgements Mekonnen AB, McLachlan AJ, Brien J-A . Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open 2016;6:
Schepel L, Lehtonen L, Airaksinen M, et al. Medication reconciliation and review for older emergency patients requires improvement in Finland. Int J Risk Safe Med 2019;30:19–31.
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