title: [Home visits by a pharmacist after discharge from hospital].
abstract: BACKGROUND
  Elderly patients using many medicines are at particular risk of making medication errors after discharge from hospital. This pilot study aims at investigating the feasibility and acceptance of improved written discharge information and home visits (by a pharmacist) to elderly patients who have newly been discharged from a medical department in a hospital.
  
  
  METHODS
  Patients (70 years and older) who needed at least 5 medicines and were about to be discharged from a medical department in a hospital, were offered home visits by a pharmacist 1, 5 and 26 weeks after discharge. A copy of the medication list was sent to their general practitioner (GP) the day the patient went home. During the home visit, the pharmacist provided information and training and recorded discrepancies between the hospital's medication list and the patients' actual medication use. 57 were invited to participate and 51 accepted the offer. During the 6-month project period, 5 patients died, one moved to a nursing home and one patient dropped out. Patients' and physicians' views on these measures were recorded.
  
  
  RESULTS
  53 discrepancies were disclosed for 29 of 51 patients during the first home visit. 26 discrepancies were disclosed during both the second and third visit; for 15/49 patients during the second and for 14/44 during the third visit. All involved GPs agreed that the medication list should be sent to the patient's GP the day the patient was discharged. Both hospital doctors and GPs regarded home visits by pharmacists to be useful for selected patients.
  
  
  CONCLUSIONS
  In conclusion, home visits by a pharmacist is feasible, well accepted by doctors and patients and may represent a useful method for reducing medication errors in newly discharged elderly patients. The improved routines for informing the GPs about patients' medication use at discharge were appreciated. A controlled intervention study is needed to substantiate the effects of the measures undertaken in this pilot study.
authors.affiliation: Sykehusapoteket Lørenskog 1474 Nordbyhagen. synnove.bergheim@sykehusapotekene.no
authors.forename: Synnøve
authors.initials: S
authors.lastname: Bergheim
authors.forename: Carl Ditlef
authors.initials: CD
authors.lastname: Jacobsen
authors.forename: Fredrik
authors.initials: F
authors.lastname: Clausen
authors.forename: Jørund
authors.initials: J
authors.lastname: Straand
mesh_terms: D000368:Aged; D001291:Attitude of Health Personnel; D003920:Diabetes Mellitus / Q000188:drug therapy; D004346:Drug Information Services; D064420:Drug-Related Side Effects and Adverse Reactions; D005240:Feasibility Studies; D005260:Female; D006299:Health Services for the Aged; D006331:Heart Diseases / Q000188:drug therapy; D006792:House Calls; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control; D010351:Patient Discharge; D004364:Pharmaceutical Preparations / Q000008:administration & dosage; D010595:Pharmacists; D010821:Physicians, Family; D010865:Pilot Projects; D019338:Polypharmacy; D012307:Risk Factors; D012646:Self Administration; D011795:Surveys and Questionnaires
chemical_list: D004364:Pharmaceutical Preparations