title: Impact of pharmacist interventions in older patients: a prospective study in a tertiary hospital in Germany.
abstract: BACKGROUND
  Inappropriate pharmacotherapy among older adults remains a critical issue in our health care systems. Besides polypharmacy and multiple comorbidities, the age-related pharmacokinetic and pharmacodynamic changes may increase the risk of adverse drug reactions and medication errors.
  
  
  OBJECTIVE
  The main target of this study was to describe the characteristics of pharmaceutical interventions in two geriatric wards (orthogeriatric ward and geriatric day unit) of a general teaching hospital and to evaluate the clinical significance of the detected medication errors.
  
  
  METHODS
  The study was conducted between August 2014 and October 2015 and was based on a triple approach that included validation of medical orders, medication reconciliation at patients' admission, and a predischarge planning appointment with the patient. The validation of medical orders was based on analyzing the suitability of the drugs prescribed, the drug dose depending on the patient's characteristics, the presence of contraindications and interactions between drugs, and the proposal of alternative drugs included in the hospital formulary.
  
  
  RESULTS
  A total of 2,307 interventions associated to a medication error in 15,282 medical orders for 1,859 older patients were recorded. The greater part of the interventions carried out on the orthogeriatric ward at admission and at discharge were due to omission of a drug in the medical order (20.0%) and clinically significant interactions requiring monitoring (30.4%), respectively. The main factor triggering pharmacist's recommendations on the geriatric day unit was clinically significant interactions (21.1%). With regard to the clinical severity of the detected errors, 68.1% were considered significant, 24.8% were of minor significance, and 7.2% were clinically serious.
  
  
  CONCLUSIONS
  Our findings show the importance of clinical pharmacist involvement in the optimization of pharmacotherapy in older adults, ensuring that they receive effective, safe, and efficient drug therapy.
authors.affiliation: Department of Pharmacy.
authors.forename: L
authors.initials: L
authors.lastname: Cortejoso
authors.affiliation: Department of Geriatrics, Hospital Nuremberg, Paracelsus Medical Private University Nuremberg, Nuremberg, Germany.
authors.forename: R A
authors.initials: RA
authors.lastname: Dietz
authors.affiliation: Department of Pharmacy.
authors.forename: G
authors.initials: G
authors.lastname: Hofmann
authors.affiliation: Department of Geriatrics, Hospital Nuremberg, Paracelsus Medical Private University Nuremberg, Nuremberg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Gosch
authors.affiliation: Department of Pharmacy.
authors.forename: A
authors.initials: A
authors.lastname: Sattler
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology*; D005260:Female; D005858:Germany; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000706:statistics & numerical data*; D059065:Medication Reconciliation / Q000706:statistics & numerical data*; D010595:Pharmacists; D010607:Pharmacy Service, Hospital / Q000592:standards*; D019338:Polypharmacy; D011446:Prospective Studies; D062606:Tertiary Care Centers
keywords: medication errors; older adults; pharmacist interventions