Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge

Pieter Cornu, Stephane Steurbaut, Tinne Leysen, Eva De Baere, C. Ligneel, Tony Mets, Alain Dupont

Research output: Chapter in Book/Report/Conference proceedingMeeting abstract (Book)

Abstract

Introduction: Medication reconciliation has been put forward as a possible solution for preventing medication errors and adverse drug events, as any discrepancy in the medication history may result in a discrepancy during hospitalization. The objective of this study was to evaluate the effect of clinical pharmacist-conducted medication reconciliation at hospital admission on the occurrence of medication discrepancies during hospitalization and at discharge.

Materials & Methods: This was a retrospective single centre cohort study of patients admitted to the acute geriatric department of a university hospital in Brussels (UZ Brussel, Belgium) who were consecutively followed up by clinical pharmacists. The clinical pharmacist-acquired medication histories were compared with the physician-acquired medication histories by an independent pharmacist. All discrepancies identified were subsequently analysed to determine if an intervention was done and was accepted, and whether the discrepancy (re)occurred during hospitalization and at discharge.

Results: The comparison of the medication histories revealed 681 discrepancies. Of the 199 patients included, 163 (81.9%) had at least one discrepancy in the physician-acquired medication history. On hospital admission, the clinical pharmacists did 386 interventions which were accepted in 279 cases(72.3%) (i.e. the medication planning was changed as advised by the clinical pharmacist, or the clinical pharmacist's intervention was correct but a well-founded reason for not changing the therapy was documented by the physician). In 77 (11.3% of all discrepancies) cases however, no intervention was made although a discrepancy occurred during the hospitalization, indicating that an intervention was
possibly warranted. A quarter of the medication history discrepancies resulted in a discrepancy during hospitalization (165; 24.2%), for the majority because the intervention was not accepted. At discharge, 278 medication history discrepancies (40.8%) resulted in discrepancies in the discharge letter accounting for 50.2% of all 554 discrepancies identified in the discharge letters.

Discussions, Conclusion: The majority of discrepancies in the medication history did not lead to a discrepancy during hospitalization due to the clinical pharmacists' interventions and because discrepancies in the medication history do not automatically translate in discrepancies during hospitalization. Half of all discrepancies at discharge found their origin in discrepant medication histories, emphasizing the importance of accurate medication histories.
Original languageEnglish
Title of host publicationESCP Conference, Dublin, Ireland, Oct.19-21, 2011
Publication statusPublished - 19 Oct 2011
EventUnknown -
Duration: 19 Oct 2011 → …

Conference

ConferenceUnknown
Period19/10/11 → …

Keywords

  • clinical pharmacy, drug related problems,
  • medication reconciliation

Fingerprint

Dive into the research topics of 'Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge'. Together they form a unique fingerprint.

Cite this