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BREAKING BARRIERS: MEDICATION SAFETY IN TRANSITIONS OF CARE

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European Statement

Clinical Pharmacy Services

Author(s)

M. Cabré Serres, T. Aguilella Vicente, E. Julián Avila, D. Rodríguez Cumplido, J.M. Pepió Vilaubí, M. Muñoz-García

Why was it done?

As a part of a multicentric medication reconciliation (MR) study in the fragile patient, one of the phases of the project included primary care reconciliation so we had to create alliances and enable effective communication channels between the two levels of care.

What was done?

During 2015, we started using direct messaging between hospital pharmacist (HP) and primary care physician. The messaging tool, which is available in SIRE and ECAP programs, allows you to send messages to all physicians caring for the patient. It also allows you to contact the usual pharmacy of the patient. Physicians receive messages automatically during the patient’s clinical course.

How was it done?

When patients were medically discharged, the HP performed MR. The HP contacted the next provider to inform them of changes in the medication list and safety alerts. When the patient visited the doctor, he already had the pharmacotherapy summary and pharmaceutical recommendations in the patient’s electronic clinical course. Afterwards, the HP assessed if the pharmaceutical interventions (PIs) had been accepted.

What has been achieved?

We started using the tool in January 2015. We performed 205 discharge reconciliations and have sent 143 messages. This would be 0.7 PIs/patient. PIs have been: 26.6% (n=38) remove medication, 21.0% (n=30) monitor treatment, 21.0% (n=30) increase adherence, 11.2% (n=16) modify dose, 8.4% (n=12) add medication, 6.3%(n=9) modify posology and 5.6% (n=8) replace medication. Finally, 72.7% (n=104) of PIs have been accepted and 27.3% (n=39) rejected. We can also analyse population characteristics and the drugs involved in the PIs.

What next?

We are breaking barriers between hospital and primary care with nexus of the HP, who has begun to be part of the medical team. We want to continue in this direction to improve the results of our PIs. We want to determine if our PIs improve health outcomes. Another current problem in the transition of care is hyperprescription treatments with proton pump inhibitors or benzodiazepines. A de-prescription programme could be the next step.

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