Communication between community and hospital pharmacists: impact on medication reconciliation at admission

Objective To evaluate the non-intentional prescription discrepancies between home medication and hospital medication for in-patients, their potential clinical impact and the impact of pharmaceutical communication between community pharmacists (CP) and hospital clinical pharmacists (HCP) to prevent them. Setting Prospective study of 278 in-patient’s files hospitalized in orthopaedic surgery + units. Methods After reconciliation by the HCP including patient interviews, GP prescription reviews and CP drug delivery analyses, we analysed patient files (prescription and patient chart) and we compared the administered drugs (home medication) to those that the patient should have received. We tracked the pharmaceutical intervention, the physician acceptance and the identified and avoided errors. The clinical impact of each discrepancy was evaluated by a team composed of a physician and a clinical pharmacist. Main outcome measure Frequency of intentional and non-intentional discrepancy (NID), evaluation of NID clinical impact and rate of NID identified and corrected by the reconciliation procedure. Results 278 consecutive patients were included in the study. 1,532 prescription lines were analysed and 471 discrepancies were observed [IC95 % = (28.43; 33.00)]. Nonintentional discrepancies (NID) affected 9.2 % of prescription lines [IC95 % = (7.7; 10.6)] and 34.2 % of patients [IC95 % = (31.3; 37.1)]. Fifty-one patients (18.3 %) had at least one NID classified as potentially harmful. Sixty-nine percent of errors at admission were identified by the reconciliation procedure including data exchanges with CP. Conclusion This study demonstrates the importance of drug reconciliation at patient’s admission by the HCP supported by communication with the CP.