Objetive:

To assess the effectiveness of the pharmaceutical intervention and characterize the types of discrepancies and errors of medication reconciliation, in the context of a program of medication reconciliation during inpatient transfers, whose origin has been other hospital or the intensive care unit.

Methods:

An eight months prospective, observational study was carried out in a secondary hospital. Patients were selected when they were transferred to a medical unit of our hospital from an intensive care unit (ICU), a coronary intensive care unit (CICU) or other hospitals. Daily, in order to conduct the reconciliation process, the Pharmacist prepared the best pharmacotherapeutical history possible, reviewing all available information about the medication the patient could be taking before, and completing the process with a clinical interview. The discrepancies requiring clarification were reported to the physician.

Results:

350 medications were reconciled in 136 patients, with a mean of 2,6 drugs per patient. 139 reconciliations were made: 68 were considered as justified discrepancies, 53 as no discrepancies and the remaining 18 as discrepancies that required clarification; the most frequent was the omission of a medication, followed by incomplete prescription and unjustified modification of dosing or way of administration. Among these 18 discrepancies, 15 were accepted by the hospital physician and prescriptions were modified. Most of the drugs with these discrepancies belonged to the anatomical-therapeutic groups: alimentary tract and metabolism, cardiovascular system, nervous system and respiratory system.

Conclusions:

The medication reconciliation process conducted by a pharmacist has proven to be useful in the identification and prevention of medication errors with potential clinical consequences for patients.

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