Analysis of an electronic medication reconciliation and information at discharge programme for frail elderly patients.
Background During care transitions, discrepancies and medication errors often occur, putting patients at risk, especially older patients with polypharmacy. Objective To assess the results of a medication reconciliation and information programme for discharge of geriatric patients conducted through hospital information systems. Setting A 1300-bed university hospital in Madrid, Spain. Method A prospective observational study. Geriatricians selected candidates for medication reconciliation at discharge, and sent an electronic inter-consultation request to the pharmacy department. Pharmacists reviewed the medication list, comparing it with electronic prescriptions, medication previously prescribed by primary care physicians and other medical records, and resolved any discrepancies. An individualized and tailored drug information at discharge sheet was sent to geriatricians and made available to primary care physicians. Main outcome measure The number and type of discrepancies, the number, type and severity of errors, and the main pharmacological groups involved. Results Medication reconciliation was performed for 118 patients with a mean age of 87 years (SD 5.9), involving a total of 2054 medications, or 17.4 per patient. Discrepancies were found in 723 (35 %) drugs, 105 of which were considered medication errors (15 %); 66 patients (56 %) had at least one error. This gave 0.9 reconciliation errors per patient reviewed and 1.6 per patient with errors. Of the 105 errors, 14 (13 %) were considered serious. The most frequent errors were incomplete prescriptions (40 %) and omissions (35 %). Conclusion An electronic medication reconciliation programme helps pharmacists detect serious medication errors in frail elderly patients and provides complete and up-to-date written information to prevent additional errors at home.
Pharmacy Department, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain. marta.moro@salud.madrid.org.
Marta
http://orcid.org/0000-0003-2302-9482
M
Moro Agud
Geriatrics Department, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain.
Rocío
R
Menéndez Colino
Geriatrics Department, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain.
María Del Coro
Mdel C
Mauleón Ladrero
Pharmacy Department, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain.
Margarita
M
Ruano Encinar
Biostatistics Department, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain.|School of Medicine, Autónoma University of Madrid, Madrid, Spain.
Jesús
J
Díez Sebastián
Pharmacy Department, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain.
Elena
E
Villamañán Bueno
Pharmacy Department, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain.
Alicia
A
Herrero Ambrosio
Geriatrics Department, La Paz University Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain.|School of Medicine, Autónoma University of Madrid, Madrid, Spain.
Juan Ignacio
JI
González Montalvo
D000369:Aged, 80 and over; D057286:Electronic Health Records; D005260:Female; D016330:Frail Elderly; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D059065:Medication Reconciliation / Q000379:methods*; D010351:Patient Discharge; D010353:Patient Education as Topic; D011446:Prospective Studies
Drug information; Geriatrics; Information technologies; Medication errors; Medication reconciliation; Seamless care; Spain