Background and importance Medication reconciliation is a clinical pharmacy process to prevent medication errors at transitions of care. We integrated this activity into the management of elderly patients in our hospital a year ago. CLEO is a comprehensive tool that assesses especially clinical impact of pharmacists’ interventions (PIs) developed by experts of the French Society of Clinical Pharmacy (SFPC). We used it to evaluate the potential clinical impact of medication reconciliation on the patient.

Aim and objectives The aim of this study was to assess unintentional medication discrepancies (UD) in admission orders with potential for patient harm (moderate or major clinical impact) with the CLEO tool.

Material and methods We conducted a prospective observational monocentric study between September 2020 and August 2021 on internal medicine patients aged over 65 years in a French hospital. They all benefitted from medication reconciliation upon admission and we used the CLEO tool to rank the clinical impact (Negative/Null/Minor/Moderate/Major/Avoids Fatality) of UD. UD were scored by two experienced clinicians.

Results 318 patients were included (mean age 82.3±8.0 years; sex ratio 0.4; mean number of prescribed drugs 8.0±4.0; mean length of stay 8.2±6.7 days). 176 patients had at least 1 UD (55%) and we found 2.1 UD per patient. 63% of UD were associated with a “moderate” clinical impact (“The PI can prevent harm that requires further monitoring/treatment, but does not lead to or does not extend a hospital stay”) and 2% were “ major” (“The PI can prevent harm which causes or lengthens a hospital stay OR causes permanent disability or handicap”).

Conclusion and relevance The identification of UD with moderate and major clinical impact underline the significance of the sustainability of medication reconciliation in routine clinical practice. Furthermore, according to the Multi-Center Medication Reconciliation Quality Improvement Studies (MARQUIS), the cost of harmful medication error to hospitals in the USA is about $4655. If we expanded to 241 UD with a moderate or major clinical impact, we could easily calculate significant annual savings to hospitals as a result of avoided harmful medication errors, providing useful input to convince hospital boards about medication reconciliation return on investment, in addition to the benefit expected for patients.

Conflict of interest No conflict of interest