Background and importance The implementation of medication reconciliation programmes is a quality standard in health centres according to the recommendations of national and international patient safety organisations to reduce medication errors during transitions of care.

Aim and objectives Main objective was to implement a medication reconciliation programme in high-risk patients admitted to a tertiary hospital. Secondary objective was to promote patient safety by detecting medication errors that occur during transitions of care.

Material and methods Selection of high-risk patients by two clinical pharmacists physically present in the Emergency Department.

At admission, pharmacists make an advanced medication review and interview the patient or carers to obtain a complete and accurate home medication list. When a potential prescribing error is detected, the pharmacist makes a pharmacotherapy recommendation (PR) to the physician.

At discharge, pharmacists review the medication list on the discharge plan and interview patients via telephone within 72 hours post-discharge to confirm that they have understood the new treatment plan. If the pharmacist detects an error, he/she makes a PR directly to the patient.

The impact was measured with the number of PR and the severity of the detected prescribing errors according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) severity index at admission and discharge.

Results Between February 2018 and September 2021, a total of 789 patients were included in the programme (53.3% women, mean age 81.3 years (SD 9.65)). Mean number of home medications at admission was 11.2 (SD 4.30). Pharmacists made a total of 1140 PR to physicians (1,5 per patient). Main types of prescribing errors were: omission of a drug (37.3%), wrong drug (23.6%), wrong dose (21.0%) and wrong frequency (11.2%). A total of 707 (62.0%) prescribing errors could have caused harm to the patient (NCC MERP severity index, Category ≥ E). Physician acceptance rate was 92.5%.

At discharge, 277 patients were interviewed by a pharmacist via telephone; 46.9% did not understand at least one aspect of the discharge medication list. Pharmacists made 336 PR to patients and 64.6% of the detected errors could have caused harm.

Conclusion and relevance We have succesfully implemented a medication reconciliation program in high-risk patients that allows us to detect medication errors at admission and discharge.

Conflict of interest No conflict of interest