RESUMEN
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 avoid a notable number of clinically relevant discrepancies and potential adverse drug events.