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NP-009 Assessment of medication discrepancies by pharmacist-led medication reconciliation at admission: a prospective study in traumatology
  1. N Ratsimalahelo1,2,3,
  2. N Perrottet1,2,
  3. J Da Silva Raposo4,
  4. O Borens4,
  5. F Sadeghipour1,2,3
  1. 1Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
  2. 2Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
  3. 3Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva and University of Lausanne, Geneva and Lausanne, Switzerland
  4. 4Department of Orthopaedics Surgery and Traumatology, Lausanne University Hospital, Lausanne, Switzerland


Background and Importance Medication errors leading to preventable adverse drug events occur mainly during transitions of care (admission/discharge from a healthcare facility, hospital interdepartmental transfers). Data on drug reconciliation in surgical wards are scarce.

Aim and Objectives The purpose of this study was to assess the prevalence of medication discrepancies in patients admitted to an orthopaedic and trauma department during the medication reconciliation process performed by a pharmacist at admission, and to identify potential risk factors.

Materials and Methods This was a prospective single-center observational study conducted over a 15-week in 2021. Eligible patients were adults hospitalized in two units of an orthopaedic and trauma department of a tertiary university hospital in Switzerland, admitted for a duration of hospitalization > 48 hours, in the presence of a chronic pathology and/or a medication at risk and/or on the physician in charge of the patient’s request. The Best Possible Medication History list was established for each patient and compared to the prescription on admission to identify medication discrepancies. These discrepancies were classified as intentional/unintentional on the basis of the medical record and, if necessary, a discussion with the physician. A multivariable analysis by logistic regression was performed to identify predictors of the ‘presence of an unintentional medication discrepancy (UMD)’.

Results 120 patients were included in the study with a median age of 71 years [IQR 63.5 – 83.5]. 71.7% of patients were taking ≥ 5 medications before admission. The median pharmaceutical time required to perform the medication reconciliation activity was 36 minutes [IQR 29 – 45]. 60.8% of admitted patients had at least one UMD on admission with a median of 2 per patient [IQR 1 – 3]. Unintentional drug omission (67.3%) and dose modification (21.2%) were the most frequently encountered UMD. 88.5% of identified UMD were corrected. Polymedication (≥ 5 medications) was the only variable associated with ‘presence of an UMD’ at a level very close to the established statistical significance level of p = 0.05 [OR 2.24, p-value 0.065].

Conclusion and Relevance This study confirms the major interest of the medication reconciliation at admission in an orthopaedic and trauma department in an elderly and polymedicated population, exposed to high-risk medications and to a risky process.

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