title: Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients.
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.affiliation: Universitair Ziekenhuis (UZ) Brussel, Department of Clinical Pharmacology and Pharmacotherapy, Jette,  Belgium.
authors.forename: Pieter
authors.initials: P
authors.lastname: Cornu
authors.forename: Stephane
authors.initials: S
authors.lastname: Steurbaut
authors.forename: Tinne
authors.initials: T
authors.lastname: Leysen
authors.forename: Eva
authors.initials: E
authors.lastname: De Baere
authors.forename: Claudine
authors.initials: C
authors.lastname: Ligneel
authors.forename: Tony
authors.initials: T
authors.lastname: Mets
authors.forename: Alain G
authors.initials: AG
authors.lastname: Dupont
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001530:Belgium; D015331:Cohort Studies; D004282:Documentation / Q000592:standards; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control*; D059065:Medication Reconciliation / Q000458:organization & administration*; D010343:Patient Admission / Q000592:standards*; D010351:Patient Discharge / Q000592:standards*; D010595:Pharmacists / Q000458:organization & administration; D010607:Pharmacy Service, Hospital / Q000379:methods; D055553:Prescription Drugs / Q000008:administration & dosage / Q000009:adverse effects; D012189:Retrospective Studies
chemical_list: D055553:Prescription Drugs