Background and importance During the pharmacotherapeutic process of patients, various drug-related problems (DRPs) may appear, some inherent to the drug itself and others derived from healthcare. 25% of medication errors in hospitalised patients are due to an incorrect reconciliation of medication at admission¹.

Aim and objectives Guarantee that patients receive the necessary chronic and hospital medications, avoiding duplications and interactions between them.

Promote adherence to treatment through oral and written pharmacotherapeutic information (FTI) upon discharge.

Material and methods Comprehensive pharmaceutical care was divided into two actions:

1 Reconciliation of medication at hospital admission: avoid DRPs that occur in the transmission of FTI between the different levels of care through the process called medication reconciliation.

2 Reconciliation and FTI, oral and written, at hospital discharge: the medication prescribed at discharge is compared with that registered during admission and FTI is provided at discharge, oral and written, to the patient and/or caregiver.

Main sources of information: clinical history, reports from medium/long stay centres, electronic prescription and personal interview with patients/relatives.

Results The average stay in the short-stay unit was 14 days. The most prevalent pathologies were: schizophrenia, followed by schizoaffective and personality disorders.

Over 6 months, all the patients admitted to the psychiatric hospital were registered, a total of 246 patients with a mean age of 45.4 (range 17–86) years and an average number of medications/patient of 7.

Primary and specialised care medication was reconciled for all of them, resulting in 170 interventions/discrepancies, and of 96 prescriptions 97.6% (166) were accepted.

During the indicated period, 24 patients (19.6%) met the FTI requirements at discharge.

Conclusion and relevance Coordination and direct and active communication between the different healthcare professionals involved in patient care increases the quality of their healthcare.

The integration of the liaison pharmacist in the hospitalisation units allows safe and efficient use of medicines. Likewise, it brings the work of the pharmacist closer to hospitalised patients, facilitating and expanding pharmaceutical care in the hospital and during care transitions.

Added value of improving adherence to treatment: the patient is provided with knowledge of their treatment through oral and written information at the time of discharge.

References and/or acknowledgements 1. Durán-García E, Fernandez Llamazares CM, Calleja-Hernandez MA. Medication reconciliation: passing phase or real need? Int J Clin Pharm 2012;34(6):797–802.

Conflict of interest No conflict of interest