title: [Medication reconciliation at hospital discharge focusing on patient with hypertension: Analysis of the output prescription].
abstract: OBJECTIVE
  To describe pharmacists' interventions made at patients hospital discharge from Department of Hypertension.
  
  
  METHODS
  This is a single-center and prospective study over an 8-week period. At hospital discharge, the pharmacist compared pre-admission and inpatient medications with discharge orders and written instructions. Pharmacists' interventions were then classified in 4 categories. All variances and discrepancies were discussed with the prescribing physician when possible.
  
  
  RESULTS
  Over the 8-week period, 154 cases were analyzed. Pharmacists' interventions at discharge underwent 48 times on 21% of the patients (n=33) but none was clinically relevant. Among these 48 cases, 40% (n=19) were rated as "inappropriate administration", 27% (n=13) were classified as "incomplete prescription", 19% (n=9) were "variances" and 4% (n=2) were due to "omission prescription". In 10% of the cases (n=5), discrepancies appeared without any possible further analysis as no discussion with the prescriber occurred.
  
  
  CONCLUSIONS
  One fifth of all patients analyzed was the subject of a pharmacists' intervention. The complementary action of the pharmacist improves the consistency of the prescriptions and strengthens patient safety.
authors.affiliation: Pôle pharmacie, hôpital Rangueil, 1, avenue du Pr-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France. Electronic address: flavie.boye@gmail.com.
authors.forename: F
authors.initials: F
authors.lastname: Boyé
authors.affiliation: Pôle pharmacie, hôpital Rangueil, 1, avenue du Pr-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
authors.forename: B
authors.initials: B
authors.lastname: Sallerin
authors.affiliation: Service de médecine interne et HTA, hôpital Rangueil, pôle cardiovasculaire et métabolique, 1, avenue du Pr-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
authors.forename: J
authors.initials: J
authors.lastname: Amar
authors.affiliation: Service de médecine interne et HTA, hôpital Rangueil, pôle cardiovasculaire et métabolique, 1, avenue du Pr-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
authors.forename: B
authors.initials: B
authors.lastname: Chamontin
authors.affiliation: Service de médecine interne et HTA, hôpital Rangueil, pôle cardiovasculaire et métabolique, 1, avenue du Pr-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
authors.forename: B
authors.initials: B
authors.lastname: Bouhanick
mesh_terms: D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001569:Benzodiazepines / Q000627:therapeutic use; D005260:Female; D005602:France; D006801:Humans; D006973:Hypertension / Q000188:drug therapy; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D008297:Male; D059065:Medication Reconciliation / Q000706:statistics & numerical data*; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data*; D061214:Patient Safety; D010595:Pharmacists; D010607:Pharmacy Service, Hospital; D055656:Prescriptions / Q000706:statistics & numerical data*; D011446:Prospective Studies; D054328:Proton Pump Inhibitors / Q000627:therapeutic use
chemical_list: D000959:Antihypertensive Agents; D000960:Hypolipidemic Agents; D054328:Proton Pump Inhibitors; D001569:Benzodiazepines
keywords: Conciliation médicamenteuse de sortie; Entretien pharmaceutique en fin d’hospitalisation; Hospital discharge medication reconciliation; Hypertension; Hypertension artérielle; Interventions pharmaceutiques; Pharmaceutical exit interview; Pharmacists’ interventions; Traceability of therapeutic changes; Traçabilité des modifications thérapeutiques