Background and importance Transitions of care have been determined to be one potential source of errors, especially in relation to medications. WHO has pointed out the need to improve patient safety at transitions for many years as the probability of communication errors increases with a patient moving between facilities, sectors and staff. Almost two thirds of medication errors happen at transitions of care and these mistakes expose patients to medication-related problems and adverse drug events.
Aim and objectives To assess the effect of pharmacist-led medication reconciliation and to evaluate if a hospitalised patient’s medication history is accurately recorded.
Materials and methods Medication reconciliation was performed by the pharmacist within 24 hours after the patient’s admission to the nursing, internal medicine or surgical ward using the validated data collection form in 5 hospitals.
Results A total of 101 patients were included in the pilot study with a mean age 73 years. A total of 218 medication discrepancies (MD) were revealed and 80% patients had at least one MD, a mean of 3.74 MDs per patient among those having MDs. 65% MDs were identified as unintentional MDs and they affected 54% patients with a maximum number of 10 discrepancies per patient case. 41% of MDs were considered clinically relevant by the joint decision of the pharmacist and the prescriber and the patient’s medication list was modified. The most common discrepancies were drug omission (50%), relating food supplements (14%), incorrect dose (10%) and frequency (5%). Older female patient taking at least 5 medications had the highest probability of discrepancies to arise.
Conclusion and relevance The results indicate that the process of collecting medication history needs improvement by implementing medication reconciliation as in 80% of cases patients’ medication list obtained by the pharmacist and nurse were not a complete match and half of the patients had at least one unintentional medication discrepancy. This finding is similar to other studies regarding medication reconciliation.
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