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PROTOCOL FOR MEDICATION RECONCILIATION AT DISCHARGE
European Statement
Patient Safety and Quality Assurance
Author(s)
Álvaro Caballero Romero, Enrique Galindo Sacristán, Fernando Malpica Chica , Enriqueta González González, Ana María Manzano Bonilla, Marcos Camacho Romera
Why was it done?
Medication errors (ME) are often identified in transitions of patients at admission to and discharge from the hospital. Medication reconciliation at discharge is an effective process to decrease the morbidity, mortality and healthcare expenses.
What was done?
A protocol for a medication reconcialiation project was designed by hospital and primary health care pharmacists.
How was it done?
The protocol has the following steps. To identify all the patients from the hospital at discharge daily. To select the polimedicated (5 or more prescribed medicament) and elderly (over 65 years old) patients. To review the discharge report in the clinical history patient in order to compare whether doctor prescriptions of medicaments (medicine, dose, posology, duration) correspond to the prescriptions included in the report at discharge. To identify discrepancies between both the discharge report and doctor prescriptions of medicaments. The discrepancies were clasified in justified and unjustified. The unjustified discrepancies were categorised as omissions, unnecesary addition, wrong medications, wrong drug frequency/dose, duplicities, pharmacological interacctions and inappropiated medicine regarding to the current clinical practice guidelines. The discrepancies are classified as high and low priority. Finally, both types of discrepancias are reported by sending emails to the specific physicians for each patient along the primary health care system. Some specific cases are discussed on phone calls by doctors and the pharmacists in order to achieve the best clinical goal for the patient.
What has been achieved?
The project was evaluated from June 2016 to May 2017. Total of discharges: 2788. Included patients: 863. Patients with discrepancies: 309 (35%). Detected discrepancies: 470. Rate discrepancies/patient: 1.52. Omissions: 122 of 470. (25.96%). Unnecesary addition: 60 of 470 (12.76%). Wrong medicine: 3 (0.63%). Wrong frequency/dose: 167 (35.53%). Duplicities: 92 (19.57%). Pharmacological interactions: 13 (2.65%). Inappropiated medicine: 13 (2.77%). Reported emails: 309/309 (100%).
What next?
Polimedicated and over 65 years old patients play an extremely important role in the current health care systems. The ME are frequent and may be particullary severe in this type of patients. To develope a protocol for medication reconciliation at discharge in order to identify potencial prescriptions problems is an oppotunity for the multidisciplinar care team to improve the patient care and decrease the expenses associated to primary health care.