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Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients.
Ann Pharmacother 2012; 46(4):484-94AP

Abstract

BACKGROUND

Medication discrepancies have the potential to cause harm. Medication reconciliation by clinical pharmacists aims to prevent discrepancies and other drug-related problems.

OBJECTIVE

To determine how often discrepancies in the physician-acquired medication history result in discrepancies during hospitalization and at discharge. Secondary objectives were to determine the influence of clinical pharmacists' interventions on discrepancies and to investigate possible patient-related determinants for experiencing discrepancies.

METHODS

This was a retrospective, single-center, cohort study of patients who were admitted to the acute geriatric department of a Belgian university hospital and followed up by clinical pharmacists between September 2009 and April 2010. Patients were limited to those 65 years or older who were taking 1 or more prescription drug. Medication reconciliation at admission, during hospitalization, and at discharge was conducted by an independent pharmacist who gathered information via chart reviews.

RESULTS

The reconciliation process at admission identified 681 discrepancies in 199 patients. Approximately 81.9% (163) of patients had at least 1 discrepancy in the physician-acquired medication history. The clinical pharmacists performed 386 interventions, which were accepted in 279 cases (72.3%). A quarter of the medication history discrepancies (165; 24.2%) resulted in discrepancies during hospitalization, mostly 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. The likelihood for experiencing discrepancies at admission increased by 47% for every additional drug listed in the medication history.

CONCLUSIONS

Discrepancies in the physician-acquired medication history at admission do not always correlate with discrepancies during hospitalization because of clinical pharmacists' interventions; however, discrepancies at admission may be associated with at least half of the discrepancies at discharge. Clinical pharmacist-conducted medication reconciliation can reduce these discrepancies, provided the erroneous information in the physician-acquired medication history is corrected and each intentional change in the medication plan is well documented during hospitalization and at discharge.

Authors+Show Affiliations

Universitair Ziekenhuis (UZ) Brussel, Department of Clinical Pharmacology and Pharmacotherapy, Jette, Belgium.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

22414793

Citation

Cornu, Pieter, et al. "Effect of Medication Reconciliation at Hospital Admission On Medication Discrepancies During Hospitalization and at Discharge for Geriatric Patients." The Annals of Pharmacotherapy, vol. 46, no. 4, 2012, pp. 484-94.
Cornu P, Steurbaut S, Leysen T, et al. Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. Ann Pharmacother. 2012;46(4):484-94.
Cornu, P., Steurbaut, S., Leysen, T., De Baere, E., Ligneel, C., Mets, T., & Dupont, A. G. (2012). Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. The Annals of Pharmacotherapy, 46(4), pp. 484-94. doi:10.1345/aph.1Q594.
Cornu P, et al. Effect of Medication Reconciliation at Hospital Admission On Medication Discrepancies During Hospitalization and at Discharge for Geriatric Patients. Ann Pharmacother. 2012;46(4):484-94. PubMed PMID: 22414793.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. AU - Cornu,Pieter, AU - Steurbaut,Stephane, AU - Leysen,Tinne, AU - De Baere,Eva, AU - Ligneel,Claudine, AU - Mets,Tony, AU - Dupont,Alain G, Y1 - 2012/03/13/ PY - 2012/3/15/entrez PY - 2012/3/15/pubmed PY - 2012/8/2/medline SP - 484 EP - 94 JF - The Annals of pharmacotherapy JO - Ann Pharmacother VL - 46 IS - 4 N2 - BACKGROUND: Medication discrepancies have the potential to cause harm. Medication reconciliation by clinical pharmacists aims to prevent discrepancies and other drug-related problems. OBJECTIVE: To determine how often discrepancies in the physician-acquired medication history result in discrepancies during hospitalization and at discharge. Secondary objectives were to determine the influence of clinical pharmacists' interventions on discrepancies and to investigate possible patient-related determinants for experiencing discrepancies. METHODS: This was a retrospective, single-center, cohort study of patients who were admitted to the acute geriatric department of a Belgian university hospital and followed up by clinical pharmacists between September 2009 and April 2010. Patients were limited to those 65 years or older who were taking 1 or more prescription drug. Medication reconciliation at admission, during hospitalization, and at discharge was conducted by an independent pharmacist who gathered information via chart reviews. RESULTS: The reconciliation process at admission identified 681 discrepancies in 199 patients. Approximately 81.9% (163) of patients had at least 1 discrepancy in the physician-acquired medication history. The clinical pharmacists performed 386 interventions, which were accepted in 279 cases (72.3%). A quarter of the medication history discrepancies (165; 24.2%) resulted in discrepancies during hospitalization, mostly 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. The likelihood for experiencing discrepancies at admission increased by 47% for every additional drug listed in the medication history. CONCLUSIONS: Discrepancies in the physician-acquired medication history at admission do not always correlate with discrepancies during hospitalization because of clinical pharmacists' interventions; however, discrepancies at admission may be associated with at least half of the discrepancies at discharge. Clinical pharmacist-conducted medication reconciliation can reduce these discrepancies, provided the erroneous information in the physician-acquired medication history is corrected and each intentional change in the medication plan is well documented during hospitalization and at discharge. SN - 1542-6270 UR - https://www.unboundmedicine.com/medline/citation/22414793/Effect_of_medication_reconciliation_at_hospital_admission_on_medication_discrepancies_during_hospitalization_and_at_discharge_for_geriatric_patients_ L2 - http://journals.sagepub.com/doi/full/10.1345/aph.1Q594?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -