Analysis of the medication reconciliation process conducted at hospital admission

To analyze the outcomes of a medication reconciliation process at admission in the hospital setting. To assess the role of the Pharmacist in detecting reconciliation errors and preventing any adverse events entailed.

A retrospective study was conducted to analyze the medication reconciliation activity during the previous six months. The study included those patients for whom an apparently not justified discrepancy was detected at admission, after comparing the hospital medication prescribed with the home treatment stated in their clinical hospital records. Those patients for whom the physician ordered the introduction of home medication without any specification were also considered. In order to conduct the reconciliation process, the Pharmacist prepared the best pharmacotherapeutical history possible, reviewing all available information about the medication the patient could be taking before admission, and completing the process with a clinical interview. The discrepancies requiring clarification were reported to the physician. It was considered that the reconciliation proposal had been accepted if the relevant modification was made in the next visit of the physician, or within 24-48 hours maximum; this case was then labeled as a reconciliation error. For the descriptive analysis, the Statistics® SPSS program, version 17.0, was used.

494 medications were reconciled in 220 patients, with a mean of 2.25 medications per patient. More than half of patients (59.5%) had some discrepancy that required clarification; the most frequent was the omission of a medication that the patient was taking before admission (86.2%), followed by an unjustified modification in dosing or way of administration (5.9%). In total, 312 discrepancies required clarification; out of these, 93 (29.8%) were accepted and considered as reconciliation errors, 126 (40%) were not accepted, and in 93 cases (29,8%) acceptance was not relevant due to a change in the situation of the patient. The highest opportunities for improvement were identified in the Gastroenterology, Internal Medicine and Surgery Units, and in the following therapeutic groups: blood and hematopoietic organs, cardiovascular system, and nervous system.

In our hospital, only a third of interventions were accepted and acknowledged as reconciliation errors. However, the medication reconciliation process conducted at admission by a Pharmacist has proven to be useful in order to identify and prevent medication errors. A better understanding of the cases in which interventions were not accepted could lead to an improvement in outcomes in the future.