title: Optimizing the pharmacotherapy of vascular surgery patients by medication reconciliation.
abstract: OBJECTIVE
  Medication errors may occur at any stage during the medication process and can lead to preventable adverse drug events and patients' harm. Pharmacists' support for reconcilable medication has been shown to be effective, rectifying errors and inaccuracies of the drug treatment and in the increase of medication safety. However, none of the previous studies focused on vascular patients. We investigated the nature and frequency of drug-related problems (DRPs) including the amount of potentially inappropriate medication (PIM) prescribed for elderly patients suffering from vascular diseases and the influence of pharmacists in the improvement of cardiovascular medication.
  
  
  METHODS
  After the patients' routine admission process, medication reconciliation was performed. Therefore, a pharmacist obtained an accurate medication use history. The patients' drug therapy was critically screened for DRPs and referring to this, intervention was made by the pharmacist and communicated to the physician if necessary. Potentially inappropriate medication in the elderly was reviewed through a retrospective analysis using the Priscus-List. DRPs were documented anonymously and classified.
  
  
  RESULTS
  We identified 138 DRPs among 105 patients. Sixty-five patients experienced at least 1 DRP, accordingly 1.3 DRPs per patient. In total, 43 unintended discrepancies between current medication and admission medication were detected with an overall rate of 0.41 per patient; 100 interventions were made of which 56 resulted in explicit recommendations for prescription changes. Drug classes frequently affected by DRPs were antihypertensive in 23.9%, antithrombotic agents in 19.3% and lipid lowering agents in 12.1%. In a retrospective analysis of the home medication, 12 definite PIM were identified in 49 elderly patients.
  
  
  CONCLUSIONS
  DRPs are common in the medication of vascular surgery patients and may be improved by pharmacists.
authors.affiliation: Pharmacy Department, RWTH University Hospital, Aachen, Germany - nhohn@ukaachen.de.
authors.forename: N
authors.initials: N
authors.lastname: Hohn
authors.forename: S
authors.initials: S
authors.lastname: Langer
authors.forename: J
authors.initials: J
authors.lastname: Kalder
authors.forename: M J
authors.initials: MJ
authors.lastname: Jacobs
authors.forename: G
authors.initials: G
authors.lastname: Marx
authors.forename: A
authors.initials: A
authors.lastname: Eisert
mesh_terms: D000367:Age Factors; D000368:Aged; D002317:Cardiovascular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D004347:Drug Interactions; D064420:Drug-Related Side Effects and Adverse Reactions / Q000209:etiology / Q000517:prevention & control; D006801:Humans; D057970:Inappropriate Prescribing; D059065:Medication Reconciliation; D008875:Middle Aged; D010343:Patient Admission; D010595:Pharmacists; D010607:Pharmacy Service, Hospital; D019338:Polypharmacy; D011300:Preoperative Care; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors; D014652:Vascular Diseases / Q000188:drug therapy* / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000009:adverse effects
chemical_list: D002317:Cardiovascular Agents