Prevalence, clinical relevance and predictive factors of medication discrepancies revealed by medication reconciliation at hospital admission: prospective study in a Swiss internal medicine ward.

Objective Medication reconciliation (MedRec) is a relevant safety procedure in medication management at transitions of care. The aim of this study was to evaluate the impact of MedRec, including a best possible medication history (BPMH) compared with a standard medication history in patients admitted to an internal medicine ward. Design Prospective interventional study. Data were analysed using descriptive statistics followed by univariate and multivariate Poisson regression models and a zero-inflated Poisson regression model. Setting Internal medicine ward in a secondary care hospital in Southern Switzerland. Participants The first 100 consecutive patients admitted in an internal medicine ward. Primary and secondary outcome measures Medication discrepancies between the medication list obtained by the physician and that obtained by a pharmacist according to a systematic approach (BPMH) were collected, quantified and assessed by an expert panel that assigned a severity score. The same procedure was applied to discrepancies regarding allergies. Predicting factors for medication discrepancies were identified. Results The median of medications per patient was 8 after standard medication history and 11 after BPMH. Total admission discrepancies were 524 (5.24 discrepancies per patient) with at least 1 discrepancy per patient. For 47 patients, at least one discrepancy was classified as clinically relevant. Discrepancies were classified as significant and serious in 19% and 2% of cases, respectively. Furthermore, 67% of the discrepancies were detected during the interview conducted by the pharmacist with the patients and/or their caregivers. The number of drugs used and the autonomous management of home therapy were associated with an increased number of clinically relevant discrepancies in a multivariable Poisson regression model. Conclusion Even in an advanced healthcare system, a standardised MedRec process including a BPMH represents an important strategy that may contribute to void a notable number of clinically relevant discrepancies and potential adverse drug events.