title: Discrepancies in medication information for the primary care physician and the geriatric patient at discharge.
abstract: BACKGROUND
  Medication discrepancies in discharge medication lists can lead to medication errors and adverse drug events following discharge.
  
  
  OBJECTIVE
  To determine the incidence and type of discrepancies between the discharge letter for the primary care physician and the patient discharge medication list as well as identify possible patient-related determinants for experiencing discrepancies.
  
  
  METHODS
  A retrospective, single-center, cohort study of patients discharged from the acute geriatric department of a Belgian university hospital between September 2009 and April 2010 was performed. Medications listed in the discharge letter for the primary care physician were compared with those in the patient discharge medication list. Based on the clinical pharmacist-acquired medication list at hospital admission and the medications administered during hospitalization, we determined for every discrepancy whether the medication listed in the discharge letter or the patient discharge medication list was correct.
  
  
  RESULTS
  One hundred eighty-nine discharged patients (mean [SD] age 83.9 [5.7] years, 64.0% female) were included in the study. Almost half of these patients (90; 47.6%) had 1 or more discrepancies in medication information at discharge. The discharge letters were often more complete and accurate than the patient discharge medication lists. The most common discrepancies were omission of a brand name in the patient discharge medication list and omission of a drug in the discharge letter. Increasing numbers of drugs in the discharge medication list (OR 1.19; 95% CI 1.07 to 1.32; p = 0.001) and discharge letter (OR 1.18; 95% CI 1.07 to 1.32; p = 0.001) were associated with a higher risk for discrepancies.
  
  
  CONCLUSIONS
  Discrepancies between the patient discharge medication list and the medication information in the discharge letter for the primary care physician occur frequently. This may be an important source of medication errors, as confusion and uncertainty about the correct discharge medications can originate from these discrepancies. Increasing numbers of drugs involve a higher risk for discrepancies. Medication reconciliation between both lists is warranted to avoid medication errors.
authors: Department of Clinical Pharmacology and Pharmacotherapy, Universitair Ziekenhuis Brussel, Jette, Belgium.
authors: Pieter
authors: P
authors: Cornu
authors: Stephane
authors: S
authors: Steurbaut
authors: Tinne
authors: T
authors: Leysen
authors: Eva
authors: E
authors: De Baere
authors: Claudine
authors: C
authors: Ligneel
authors: Tony
authors: T
authors: Mets
authors: Alain G
authors: AG
authors: Dupont
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006785:Hospitals, University / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D059065:Medication Reconciliation / Q000706:statistics & numerical data*; D010351:Patient Discharge / Q000706:statistics & numerical data*; D058007:Physicians, Primary Care