Medication reconciliation to solve discrepancies in discharge documents after discharge from the hospital.

backgroundWhen patients are admitted to, and discharged from hospital there is a high chance of discrepancies and errors occurring during the transfer of patients' medication information. This often causes drug related problems. Correct and fast communication of patients' medication information between community pharmacy and hospital is necessary.

objectiveTo investigate the number, type, and origin of discrepancies within discharge documents and between discharge documents and information in the pharmacy computer system, concerning the medication of patients living independently when they are discharged from hospital. Second, to test which variables have an impact on the number of discrepancies found and to study the time spent on the medication reconciliation process.

settingOne quality-certified community pharmacy in the Netherlands.

methodsPharmacists reviewed discharge documents of patients discharged over one year. This information was compared to information available in the pharmacy computer system. Discrepancies were discussed with medical specialists and/or general practitioners. Type and origin of discrepancies were classified. Differences in variables between hospitals were tested using Independent-Samples Mann-Whitney U Test and Pearson Chi Square test. Poisson regression analysis was performed to test the impact of variables on the number of discrepancies found.

main outcome measureNumber, type and origin of discrepancies for all independently living patients discharged from the hospital.

resultsDuring the study period, 100 discharges took place and were analyzed. No differences were found between the two main hospitals, a university hospital and a teaching hospital. In total, 223 discrepancies were documented. Sixty-nine discharges (69.0 %) required consultation with a patients' medical specialist. A majority of the discrepancies (73.1 %) have their origin in hospital information. The number of discrepancies found increased with the number of medicines prescribed at discharge. The community pharmacist spent, on average, 45 min on the medication review after discharge. This included 11 min for counseling the patient.

conclusionMany discrepancies were found between different information sources at patient discharge from hospital. A majority of the discrepancies had their origin in hospital information. The number of medicines after discharge was related to the number of discrepancies found. The medication reconciliation process took an average of 45 minutes per patient.