RESUMEN
Background During care transitions, discrepancies and medication errors often occur, putting patients at risk, especially older patients with polypharmacy. Objective To assess the results of a medication reconciliation and information programme for discharge of geriatric patients conducted through hospital information systems. Setting A 1300-bed university hospital in Madrid, Spain. Method A prospective observational study. Geriatricians selected candidates for medication reconciliation at discharge, and sent an electronic inter-consultation request to the pharmacy department. Pharmacists reviewed the medication list, comparing it with electronic prescriptions, medication previously prescribed by primary care physicians and other medical records, and resolved any discrepancies. An individualized and tailored drug information at discharge sheet was sent to geriatricians and made available to primary care physicians. Main outcome measure The number and type of discrepancies, the number, type and severity of errors, and the main pharmacological groups involved. Results Medication reconciliation was performed for 118 patients with a mean age of 87 years (SD 5.9), involving a total of 2054 medications, or 17.4 per patient. Discrepancies were found in 723 (35 %) drugs, 105 of which were considered medication errors (15 %); 66 patients (56 %) had at least one error. This gave 0.9 reconciliation errors per patient reviewed and 1.6 per patient with errors. Of the 105 errors, 14 (13 %) were considered serious. The most frequent errors were incomplete prescriptions (40 %) and omissions (35 %). Conclusion An electronic medication reconciliation programme helps pharmacists detect serious medication errors in frail elderly patients and provides complete and up-to-date written information to prevent additional errors at home.