Background and importance The integration of the hospital pharmacist into a multidisciplinary team is needed due to the increase in hospital admissions of complex chronic patients.

Aim and objectives To describe discrepancies and potentially inappropriate prescriptions (PIPs) of medications detected by the pharmacist, integrated into multidisciplinary team, in complex chronic patients (CCP) hospitalised in the chronic patient unit (CPU).

Material and methods This was a descriptive and prospective 5 month analysis (June to November 2019). We developed a protocol to standardise the pharmacotherapeutic plan review of all patients admitted to the CPU. We also developed a registry model of pharmaceutical interventions (PI). Anthropometric and demographic patient data were analysed (sex, age and number of chronic medications). A patient/care giver interview was conducted at hospital admission and the following PI were registered:

• Reconciliation: detection of unjustified discrepancies when comparing outpatient drug with hospital therapy.

• Adequacy: detection of PIPs using explicit/implicit criteria with CheckTheMeds software.

Individualised strategies based on the prescription’s evidence of adequacy were communicated verbally and also by means of the electronic medical records.

Results 138 hospitalised CCP were included in the study, 58.7% men, with a mean age of 82.25±9.4 years. The average number of drugs administered per patient was 10.83±5.5. For all prescribed drugs (1490), discrepancies were found for 623 (40.81%), meaning that 127 patients presented with discrepancies from which 56.02% were justified. The average reconciliation errors were 4.5±2.9 per patient and these were: omission (50%), different route of administration, different dose or frequency (36.9%), contraindicated drug (9.9%), duplicity (2.6%) and different drug (0.7%).

100% of patients had at least one PIP and the total number of PIPs was 481 (3.5/patient). The most common PIPs were related to drugs that increased the risk of falls (154 (32%)) and CNS related drugs (140 (29%)). PIPs related to greater duration than that indicated in the technical data sheet in the benzodiazepine group (83 patients) and duplicity (67 patients) were also detected.

Conclusion and relevance Pharmacist inclusion on the equipment allows an exhaustive review of pharmacological therapy, an important role in patient safety (polypharmacy, patient complexity, etc). The next step is to measure the results of the PI performed to measure the magnitude of the effect of the intervention.

Conflict of interest No conflict of interest