Golniški simpozij 2011 Zbornik povzetkov

Comprehensive medication history:
the need for the implementation
of medication reconciliation processes
Lea Knez 1 , Renata Reæonja 1,2 , Stanislav Øuøkoviœ 1 , Mitja Koønik 1 , Aleø Mrhar 2
1
Faculty of Pharmacy, University of Ljubljana
2
University Clinic of Respiratory and Allergic Diseases, Golnik
Background
Comprehensive medication history (CMH) is of outmost importance for patient evaluation and prescription
of drug treatment upon hospital admission. The aim of this study was to assess the need
for the implementation of medication reconciliation processes into clinical practice.
Method
Patients admitted to a teaching hospital in Slovenia were randomly selected and included in the
study. For every patient a CMH was obtained by a research pharmacist using different sources of information.
Next, medication history in the hospital medical record was reviewed. Prescription of medicines
was assessed for completeness of information and discrepancies between both medication
histories were recorded and classified.
Results
Overall, 108 patients with a median age of 73 years were included. The research pharmacist recorded
the use of 651 medicines, of which 94.9% provided all relevant details for drug identification and administration.
Less medicines (464) were recorded in the hospital medical record as compared to the
CMH (paired t-test, p>0.001) and only 42.0% of these medicines were evaluated as complete. When
comparing the medication history in the medical record with the CMH, at least one discrepancy was
detected in 72.4% of medicines and was often present in the medication order on the drug chart
(76.2%) and in the discharge letter (69.9%). Discrepancies often arose due to medicine’s omission
(20.9%) and medicine’s commission (6.5%).
Conclusions
The high rate of discrepancies between the recorded drug history and CMH reported in our study
shows the need for implementation of medication reconciliation practices. Pharmacists’ participation
in admission reconciliation, as described in this study, led to more complete and accurate drug
histories. In the study hospital, pharmacist-led CMH have been introduced in a research framework
within which the benefits of this service for the reduction of medication errors and adverse drug
events are being studied against routine practice in a randomised trial.
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