title: Drug related problems after discharge from an Australian teaching hospital.
abstract: OBJECTIVE
  To reconcile patients' medicines and to classify drug related problems identified during medication review conducted after discharge from hospital.
  
  
  METHODS
  Patients were discharged from the cardiology unit of Westmead Hospital after recruitment into the Westmead Medicines Project which ran from 2004 to 2007.
  
  
  METHODS
  This retrospective study involved an analysis of drugs, diseases and drug related problems in medication review reports available for 76 out of 85 patients who received a Home Medicines Review (HMR). Data sources for medication reconciliation and analyses also included hospital discharge summaries (n = 70) and GP referrals for HMR (n = 44). Comprehensive clinical profiles were constructed for the 76 subjects whose drug related problems were identified, coded, and then classified from their HMR reports.
  
  
  METHODS
  Number, type, distribution and international classification of drugs, diseases and drug-related problems.
  
  
  RESULTS
  Patients were prescribed drugs for a broad range of cardiovascular, circulatory, endocrine, respiratory and digestive system diseases. Mean number of drugs per patient in discharge summaries: 8.7 ± SD 3.3 (range 3-19); in GP referrals: 8.9 ± SD 4.3 (range 2-23); and in HMR reports: 10.8 ± SD 4.0 (range 3-24). Mean number of diseases per patient in discharge summaries: 4.1 ± SD 2.9 (range 1-11); and in HMR reports: 4.7 ± SD 2.6 (range 1-12). A total of 398 drug related problems were identified for 71 (93.3%) patients with mean 5.6 ± SD 4.3 problems (range 1-21). The most frequently recorded problems were the patients' uncertainty about drug aim: n = 128 (32.0%); potential interactions n = 89 (22.4%); and adverse reactions n = 60 (15.1%).
  
  
  CONCLUSIONS
  This study showed that patients recently discharged from a tertiary care hospital had a significant number of drug related problems. Classification of drugs and diseases revealed a broad range of non-cardiovascular medicines and conditions in the patients from an acute care cardiology unit. We found that home medicines review provided continuity of care and an opportunity for medication reconciliation which revealed marked differences in number of drugs, between hospital discharge and medicines review. The patients' uncertainly about their drugs and their diverse range of co-morbidities indicated the need for timely counselling by pharmacists in the community.
authors.affiliation: Faculty of Pharmacy A15, The University of Sydney, Sydney, NSW, 2006, Australia.
authors.forename: Glena R
authors.initials: GR
authors.lastname: Ellitt
authors.forename: Ellinor
authors.initials: E
authors.lastname: Engblom
authors.forename: Parisa
authors.initials: P
authors.lastname: Aslani
authors.forename: Tommy
authors.initials: T
authors.lastname: Westerlund
authors.forename: Timothy F
authors.initials: TF
authors.lastname: Chen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D003157:Community Pharmacy Services / Q000458:organization & administration; D003266:Continuity of Patient Care / Q000458:organization & administration; D037001:Directive Counseling / Q000458:organization & administration; D004347:Drug Interactions; D017723:Drug Utilization Review / Q000706:statistics & numerical data*; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D059065:Medication Reconciliation / Q000706:statistics & numerical data*; D054539:Medication Therapy Management / Q000458:organization & administration; D008875:Middle Aged; D010351:Patient Discharge; D010595:Pharmacists; D012189:Retrospective Studies