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4CPS-032 Pharmaceutical interventions for medication reconciliation in complex chronically ill patients
  1. P Ciudad Gutierrez1,
  2. A Rodríguez Pérez1,
  3. L Rodríguez De Francisco1,
  4. P Suárez Casillas1,
  5. M Espinosa Malpartida2,
  6. S Lora1,
  7. E Hevia Álvarez1
  1. 1Hospital Universitario Virgen del Rocío, Hospital Pharmacy, Sevilla, Spain
  2. 2Hospital Universitario Virgen del Rocío, Internal Medicine, Sevilla, Spain


Background and Importance Elderly patients who receive chronic medication for multiple pathologies have a high risk of suffering from medication discrepancies and adverse drug events. The role of pharmacists is vital to improve health outcomes by avoiding these medication errors.

Aim and Objectives To analyse the pharmaceutical interventions (PIs) of medication reconciliation in hospitalised multipathological patients over 65 years of age and to evaluate the degree of acceptance by the physicians.

Material and Methods A prospective observational study was conducted between 1 March 2023 and 15 April 2023. We analysed the PIs on therapeutic conciliation performed in multipathological patients admitted to the hospitalisation ward where the pharmacist has recently been integrated in collaboration with an internist and a nurse.

The following variables were collected number of patients admitted to the ward and those on whom PIs were performed, pathologies involved according to the drugs used, number and type of PIs identified. In addition, the degree of acceptance of the PIs was measured and PIs were identified with drugs considered high-risk in chronic patients according to the MARC list.

Results Eighty-three patients were admitted to the Internal Medicine hospitalisation ward. Of the total number of patients, 52 PIs were performed in 33 patients. The nature of the diseases associated with PIs were cardiovascular (n=16.48%), metabolic-renal (n= 9.28%), neurological (n= 5.15%) and respiratory (n=3.9%).

The recommendations made in the PIs were: discontinuation of medication (n=16), dosage adjustment (n=14), prescription of medication (n=11), substitution of the drug for a more effective one (n=7), exchange of the drug for a therapeutic equivalent (n=3) and change of the route of administration (n=1).

The degree of acceptance was 86.54%.

Of the PIs performed, 27% (n=14) involved a high-risk drug. Specifically, loop diuretics (4), anticoagulants (4), antiplatelet agents (1), beta-blockers (2), NSAIDs (1), hypoglycaemic agents (1) and insulins (1).

Conclusion and Relevance Most of the PIs were related to the addition or discontinuation of a drug, as well as to the dose adjustment of a drug. The degree of acceptance of the PIs was very high, which reinforces the role of the pharmacist within a multidisciplinary team.

Conflict of Interest No conflict of interest.

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