[Medication reconciliation at hospital discharge focusing on patient with hypertension: Analysis of the output prescription]

Abstract

Purpose: To describe pharmacists' interventions made at patients hospital discharge from Department of Hypertension.

Methods: This is a single-center and prospective study over an 8-week period. At hospital discharge, the pharmacist compared pre-admission and inpatient medications with discharge orders and written instructions. Pharmacists' interventions were then classified in 4 categories. All variances and discrepancies were discussed with the prescribing physician when possible.

Results: Over the 8-week period, 154 cases were analyzed. Pharmacists' interventions at discharge underwent 48 times on 21% of the patients (n=33) but none was clinically relevant. Among these 48 cases, 40% (n=19) were rated as "inappropriate administration", 27% (n=13) were classified as "incomplete prescription", 19% (n=9) were "variances" and 4% (n=2) were due to "omission prescription". In 10% of the cases (n=5), discrepancies appeared without any possible further analysis as no discussion with the prescriber occurred.

Conclusion: One fifth of all patients analyzed was the subject of a pharmacists' intervention. The complementary action of the pharmacist improves the consistency of the prescriptions and strengthens patient safety.

Keywords: Conciliation médicamenteuse de sortie; Entretien pharmaceutique en fin d’hospitalisation; Hospital discharge medication reconciliation; Hypertension; Hypertension artérielle; Interventions pharmaceutiques; Pharmaceutical exit interview; Pharmacists’ interventions; Traceability of therapeutic changes; Traçabilité des modifications thérapeutiques.