title: Clinical pharmacist-led program on medication reconciliation implementation at hospital admission: experience of a single university hospital in Croatia.
abstract: OBJECTIVE
  To evaluate the clinical pharmacist-led medication reconciliation process in clinical practice by quantifying and analyzing unintentional medication discrepancies at hospital admission.
  
  
  METHODS
  An observational prospective study was conducted at the Clinical Department of Internal Medicine, University Hospital Dubrava, during a 1-year period (October 2014 - September 2015) as a part of the implementation of Safe Clinical Practice, Medication Reconciliation of the European Network for Patient Safety and Quality of Care Joint Action (PASQ JA) project. Patients older than 18 years taking at least one regular prescription medication were eligible for inclusion. Discrepancies between pharmacists' Best Possible Medication History (BPMH) and physicians' admission orders were detected and communicated directly to the physicians to clarify whether the observed changes in therapy were intentional or unintentional. All discrepancies were discussed by an expert panel and classified according to their potential to cause harm.
  
  
  RESULTS
  In 411 patients included in the study, 1200 medication discrepancies were identified, with 202 (16.8%) being unintentional. One or more unintentional medication discrepancy was found in 148 (35%) patients. The most frequent type of unintentional medication discrepancy was drug omission (63.9%) followed by an incorrect dose (24.2%). More than half (59.9%) of the identified unintentional medication discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration in the patient.
  
  
  CONCLUSIONS
  Around 60% of medication errors were assessed as having the potential to threaten the patient safety. Clinical pharmacist-led medication reconciliation was shown to be an important tool in detecting medication discrepancies and preventing adverse patient outcomes. This standardized medication reconciliation process may be widely applicable to other health care organizations and clinical settings.
authors.affiliation: Ivana Marinović, Hospital Pharmacy, University Hospital Dubrava, Av. G. Šuška 6, Zagreb, Croatia, imarinov@kbd.hr.
authors.forename: Ivana
authors.initials: I
authors.lastname: Marinović
authors.forename: Srećko
authors.initials: S
authors.lastname: Marušić
authors.forename: Iva
authors.initials: I
authors.lastname: Mucalo
authors.forename: Jasna
authors.initials: J
authors.lastname: Mesarić
authors.forename: Vesna
authors.initials: V
authors.lastname: Bačić Vrca
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017523:Croatia; D005260:Female; D006760:Hospitalization; D006785:Hospitals, University / Q000458:organization & administration*; D006801:Humans; D008297:Male; D008508:Medication Errors; D059065:Medication Reconciliation / Q000458:organization & administration*; D008875:Middle Aged; D010343:Patient Admission; D010607:Pharmacy Service, Hospital / Q000458:organization & administration*; D010820:Physicians; D055553:Prescription Drugs; D011446:Prospective Studies; D011787:Quality of Health Care; D014495:Universities
chemical_list: D055553:Prescription Drugs