Background and importance Heart failure (HF) affects 15% of the population between 70 and 80 years. It causes 3–5% of hospitalisations, 50% of which could be avoided. Hence a multidisciplinary HF day hospital (HFDH) was recently created in our centre where the clinical pharmacist performs the medication reconciliation (MR) process and identifies, resolves and prevents drug related problems (DRP).
Aim and objectives To analyse the interventions carried out by the clinical pharmacist in the HFDH for the first 6 months.
Material and methods Every day the clinical pharmacist performs the MR process for one patient, checking the patient´s clinical records, blood tests and all prescriptions from the different specialists and primary doctor. After that, the pharmacist interviews the patient to confirm all the medication they are taking and how they are taking it. We identified medication discrepancies and DRP, and made a medication list with the problems detected and our recommendations. A reconciliation report was added into the patient’s electronic medical record and who will perform the necessary changes in the treatment was discussed with the physician, before the medical appointment. Finally, the pharmacist explained and provided a complete updated medication list to the patient, with all the instructions needed.
When discrepancies were found, they are classified as: discrepant dosage, drug omission and/or wrong drug. DRP were classified as wrong dose, wrong frequency, therapeutic duplicity, interaction, lack of adherence, wrong/missed high risk drug and wrong/missed low risk drug. The discrepancies and problems detected were registered in an Excel file.
Results Throughout the study period, 162 MR reports were made, 111 directed to cardiology and 51 to internal medicine. A median of two discrepancies per patient were detected (minimum 0 and maximum 14). Regarding DRP, an average of one problem per patient was found: 62% wrong/missed low risk drug, followed by therapeutic duplicity (12%), wrong dose (10%; mostly involving diuretics and statins), wrong/missed high risk drugs (8%), lack of adherence (3%), incorrect frequency (3%) and interaction (2%).
Conclusion and relevance The clinical pharmacist plays a key role in the HFDH, performing the MR process and identifying, resolving and preventing DRP. This study showed the importance of working near the HF patient, as a member of the multidisciplinary team.
Conflict of interest No conflict of interest
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