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4CPS-204 Medicine reconciliation at hospital discharge
  1. I Martinez Aguirre,
  2. A Revuelta Amallo,
  3. JA Domínguez Menéndez,
  4. U Blazquez Urtizberea,
  5. M Alonso Diez,
  6. E Fernández Díaz,
  7. A Aguirrezabal Arredondo
  1. Hospital De Basurto, Pharmacy Department, Bilbao, Spain


Background and importance It has been proven that an updated pharmacotherapeutic report means improvements in patient safety and system efficiency.

Aim and objectives To describe and analyse medicine reconciliation errors (MRE) and to determine awareness of prescribers of keeping the treatment report updated at medical discharge.

Material and methods This was a prospective study over a period of 17 weeks, involving all inpatients from the internal medicine ward (IM), cardiology ward (CAR) and oncology ward (ONC), for 8 weeks, 6 weeks and 3 weeks, respectively. Variables collected were age, sex, number of new medications, number of discrepancies not justified requiring clarification, type of MRE, communicated MRE and number of acceptances, and number of patients that received pharmaceutical care at discharge. On admission, data were collected by the pharmacist from an interview with the patient. All detected discrepancies were communicated to the physician to modify and update the treatment before discharge. The pharmacist conducted a final interview, where all modifications and new drugs were explained. Updated treatment and discharge reports were given after resolving patient doubts.

Results A total of 151 patients were analysed with a mean age of 75±13 and 46.3% were women. The number of not justified discrepancies identified were 116, corresponding to IM 58.6% (68), CAR 27.6% (32) and ONC 13.8% (16). Classification of the discrepancies: dosage error 30.2% (35); not indicated or contraindicated for current clinical situation 24.1% (28); omission error 22.4% (26); commission error 16.4% (19); mistaken drug 1.7% (2); incomplete prescription 1.7% (2); and duplicity 3.4% (4). A total of 104 discrepancies were communicated and discussed with the physicians: 49% (51) of the discrepancies were accepted and 31.1% (47) of the discharge reports were incomplete, which means the dosage or duration of treatment and changes established were not included. New drugs were started in 74.8% of inpatients and pharmaceutical care was offered to 80.5% (91) before discharge.

Conclusion and relevance The pharmacist integration has facilitated the acceptance of pharmaceutical interventions and has prevented MRE on discharge, where the most prevalent one was dosage discrepancy. This has raised awareness among all professionals about the importance of updating the medical history. All concerns about discharge medication were resolved in almost 80% of discharges.

References and/or acknowledgements No conflict of interest.

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