Conciliació de la medicació a l´ingrés i alta d´un Servei de Medicina Interna d´un hospital comarcal


Ribera Brió, Ramón


Even though big efforts are made daily by health professionals to provide reliable and quality services, this goal is not always achieved, and often undesirable episodes occur, like medication errors or adverse drug reactions, that eventually can cause patient harm. In this context, medication reconciliation is a valuable procedure capable of reducing medication related problems and significantly increase patient safety along transitions of care, especially if carried out by a multidisciplinary team.
The main goal of this study is performing medication reconciliation in a multidisciplinary manner, with the collaboration of both physician and pharmacist, at admission and at discharge from hospital, also analyse and classify the identified discrepancies (intentional and unintentional) and the drugs that cause them. We also proposed to analyse other variables, like renal function, length of hospitalisation or the number of drugs prescribed by sex.
From April to July 2022, a prospective and observational study was conducted at the internal medicine service at a hospital in Barcelona region. All the patients admitted to hospital during this period and were under the care of the physician were enrolled in the study. To gather the patient information different sources were consulted (Electronic Health Record, patient-held medication lists), and the patient was interviewed at admission with the aim to obtain the Best Possible Medication History (BPMH). Medication reconciliation was performed together, with pharmacist and physician collaboration, comparing information obtained with the BPMH and the medication lists prescribed at admission and at discharge. Primary outcome was frequency of unintentional discrepancies at admission and at discharge from hospital and secondary outcomes were length of stay by renal function, number of medications and cholinergic burden per sex. Among the 40 participants enrolled in the project, 14 and 3 unintentional discrepancies were identified at admission and discharge respectively, accounting for 2.9% of total discrepancies. Omission of medications was the most frequently identified unintentional discrepancy at hospital admission, and “cardiovascular system” and “blood and blood forming organs” were the types of drugs with the highest rates of unintentional discrepancies. Patients with renal insufficiency tended to have longer hospital stays than patients with normal renal function, women tended to have more drug prescriptions and a higher cholinergic burden compared to men, and the number of discrepancies identified at hospital admission was superior to the number of discrepancies at discharge.
Medication reconciliation is an indispensable process to provide a safety health care along transitions of care. If carried out in a multidisciplinary collaboration, the benefits can be even better, significantly reducing the number of unintentional drug discrepancies, accounting for medications good use and promoting a more efficient health service.



Ibáñez i Nolla, Jordi


IQS SE - Undergraduate Program in Pharmacy