Comprehensive medication management (CMM): Application of a new pharmaceutical practice in onco-hematology.

The integration of a large number of drugs, such as antineoplastic agents and cancer-related supportive care drugs, into the management of cancer patients exposes them to an increased number of drug-related problems (DRP). Clinical pharmacists contribute to drug management by actively intervening in detected DRP. The aim of this study is to assess the impact of the applying a clinical pharmacist-driven comprehensive medication management (CMM) service to onco-hematology patients. This prospective interventional study was carried out over six-month duration, specifically from November 06, 2022 to April 5, 2023 in the oncology and hematology departments of the EHU Oran. The adherence to treatment was evaluated using the 8-item Morisky Medication Adherence Scale (MMAS). Whereas data related to the patient's general condition and medication history was assessed using the Pharmaceutical Care Network Europe (PCNE) Classification for Drug-Related Problems V9.1. Among the 130 patients included in the study, a total of 879 DRP were identified, with a mean of 6.78 (±1.72) DRP/patient, half of which were related to efficacy (51%). Almost half of our sample (44.6%) did not adhere to their treatment. The most frequent cause of DRP, accounting for (19.9%) of the cases, was the inappropriate administration by a health professional. A total of 875 pharmaceuticals interventions (PI) were proposed, 67.2% of which were focused at the drug level. The PI acceptance rate was 94.1%. The integration of CMM services in onco-hematology played an important role in optimizing dosing regimen and treatment administration methods, as well as preventing iatropathology in the management of cancer patients.

[The clinical pharmacist, an essential element in the new gradation of care for ambulatory patients]. / Le pharmacien clinicien, un maillon indispensable dans la nouvelle gradation de prise en charge des patients ambulatoires.

OBJECTIVE: Pharmaceutical presence in oncology allows the clinical pharmacist to integrate tripartite consultations for primary prescription of oral anticancer drugs. The aim of the study is to describe the deployment of the clinical pharmacy activity in 2 oncology departments since its implementation in 2019, to assess the financial gain of the pharmaceutical interventions through the new gradation of outpatient management published on September 10, 2020, and finally to assess their satisfaction following the deployment of this pathway. METHOD: A retrospective study was conducted to collect pricing data for oral therapy interviews in patients between January 2019 and December 2022. To complement this, a satisfaction survey was conducted by the oral therapy pharmaceutical team between 01/01/2022 and 12/31/2022 among patients undergoing treatment. RESULTS: 579 patients received a targeted pharmaceutical interview as part of the oral therapy patient pathway. The average invoiced amount of a pharmaceutical consultation carried out as part of a tripartite first prescription was 355.44 euros. The 579 patients who benefited from a targeted pharmaceutical interview generated a revenue of 87,545 euros for the hospital. In terms of evaluating patient satisfaction, 163 usable responses were received out of 267 patients questioned, representing a response rate of 61%, with an overall score of 9.1/10. CONCLUSION: Pending the introduction of a specific remuneration for clinical pharmacy activities, the valuation of tripartite consultations is a lever for financing clinical pharmacy activities in hospitals.

Assessing the applicability and appropriateness of ChatGPT in answering clinical pharmacy questions.

OBJECTIVES: Clinical pharmacists rely on different scientific references to ensure appropriate, safe, and cost-effective drug use. Tools based on artificial intelligence (AI) such as ChatGPT (Generative Pre-trained Transformer) could offer valuable support. The objective of this study was to assess ChatGPT's capacity to correctly respond to clinical pharmacy questions asked by healthcare professionals in our university hospital. MATERIAL AND METHODS: ChatGPT's capacity to respond correctly to the last 100 consecutive questions recorded in our clinical pharmacy database was assessed. Questions were copied from our FileMaker Pro database and pasted into ChatGPT March 14 version online platform. The generated answers were then copied verbatim into an Excel file. Two blinded clinical pharmacists reviewed all the questions and the answers given by the software. In case of disagreements, a third blinded pharmacist intervened to decide. RESULTS: Documentation-related issues (n=36) and drug administration mode (n=30) were preponderantly recorded. Among 69 applicable questions, the rate of correct answers varied from 30 to 57.1% depending on questions type with a global rate of 44.9%. Regarding inappropriate answers (n=38), 20 were incorrect, 18 gave no answers and 8 were incomplete with 8 answers belonging to 2 different categories. No better answers than the pharmacists were observed. CONCLUSIONS: ChatGPT demonstrated a mitigated performance in answering clinical pharmacy questions. It should not replace human expertise as a high rate of inappropriate answers was highlighted. Future studies should focus on the optimization of ChatGPT for specific clinical pharmacy questions and explore the potential benefits and limitations of integrating this technology into clinical practice.

[Validation of the French version of the Assessment Tool for Hospital Admissions Related to Medications (AT-HARM10) to detect drug-related hospitalizations]. / Validation d'une version française de l'outil AT-HARM10 pour la détection des hospitalisations liées au médicament.

Admissions of the elderly related to medication errors are frequent in hospital, more than half would be avoidable, but there is currently no validated method in French to identify them. The objective of this work was to validate the French version of the AT-HARM10 tool in order to use it for patients admitted in our healthcare facilities. The tool has 10 questions. A positive response to any of the first 3 questions identify admissions that are unlikely to be drug-related. A positive response to one of the following 7 questions identify possible medication-related admissions. For semantic and linguistic validation, we performed cross-validation with forward-backward translation. To clinically validate the method, we conducted a retrospective study including patients over 65 admitted to short-stay units (UHCD) and to orthopedic surgery units in two French hospitals. Two hundred and sixty-six (266) patients were included ; 166 patients admitted to UHCD (mean age 86.0±5.7 years; sex ratio 0.66; mean number of drugs prescribed 7.7±3.8) and 100 patients admitted to orthopedic units (mean age 85.2±6.1 years; sex ratio 0.43; mean number of prescribed drugs 6.4±3.6). We identified 55 % of admissions probably related to medication in UHCD and 76 % in orthopedic units (p<0.05). The most represented item was P5 in both groups (Might [side] effects of the medications the patient was taking [prescribed or not prescribed] prior to hospitalization have caused the admission [including over-treatment] ? The validated AT-HARM10 tool is now integrated into our clinical pharmacy practices and medication reviews are offered as a priority to patients admitted for iatrogenic reasons.

[SARS-COV-2 pandemic: Involvement of the hospital pharmacist in securing patient care]. / Pandémie à SARS-COV-2 : implication du pharmacien hospitalier dans la sécurisation de la prise en charge des patients.

OBJECTIVES: In the context of the SARS-CoV-2 pandemic, hospital pharmacists supported the implementation of recommendations and ensured the safety of patient medication management. The aim of this study is to establish the interest of the involvement of the hospital pharmacist in this context by describing and comparing the activities carried out with patients with COVID-19 and those without. METHODS: During the study period, data on clinical pharmacy activities with hospitalized patients were collected and analyzed: pharmaceutical analysis of prescriptions, participation in multi-professional consultation meetings (RCP) dedicated to COVID-19, and monitoring of adverse events. RESULTS: The activities concerned 1483 patients, including 444 with COVID-19, resulting in 575 pharmaceutical interventions (PI). The main problems identified were overdoses, untreated indications, and drug-drug interactions (DDI). AMIs were significantly more common in patients with COVID-19, with 73.3% involving disease-specific therapies. Eleven PIs had a life-threatening impact, 189 a major impact. During the PCRs, 36 PIs were performed for 59% of the patients presented. A pharmacovigilance report was performed for a quarter of patients treated with hydroxychloroquine and 33% of patients treated with lopinavir/ritonavir. CONCLUSIONS: This study demonstrates the value of involving hospital pharmacists in the drug management of patients with COVID-19, particularly with the evolution of available therapies and the implementation of vaccination, in order to reduce the spread of SARS-COV2 and limit the appearance of resistance.

Impact of clinical pharmacist interventions in a bone and joint infection orthoseptic surgery unit.

OBJECTIVES: To assess the impact of interventions of a clinical pharmacist in a unit of orthopedic surgery specialized in bone and joint infections. METHODS: Daily, in routine, a clinical pharmacist analyzed medication prescribed to inpatients via a computerized physician order entry (CPOE) (Phedra software). His attention was particularly focused on the impact of antibiotics on other medications. For this study, all of the pharmacist interventions (PI) have been retrospectively collected, then anonymized, and assessed over a two-month period. RESULTS: Thirty-eight patients were hospitalized during the study period, with a mean age of 63 years old. Forty-five interventions were identified which represents a mean of 1.18 pharmaceutical interventions per patient. Most of them concerned lack of follow-up (24%) and drug-drug interactions (22%) and widely non-anti-infectious medication (35 interventions) with levothyroxine (10 interventions) as the most involved non-anti-infectious molecule. Among antibiotics, with respectively 9 and 8 interventions, rifampicin and fluoroquinolones (6 interventions for moxifloxacin) were the most concerned notably for drug-drug interactions with usual treatment. CONCLUSION: In this observational retrospective study, 1.18 pharmacist interventions (PI) per patient were observed. Most of them are lack of follow-up and drug-drug interactions especially with usual treatment of patients. Moxifloxacin and rifampicin were the most antibiotics involved. Patients' characteristics (older, polypharmacy), long-term hospitalization and surgery are known to be predictive factors of medication errors and this study highlights the importance of the presence of clinical pharmacist in orthopedic surgery wards.

[The "Gradation instruction" of care: An opportunity to integrate clinical pharmacy activities in the cancer patient journey]. / Instruction de gradation des soins : une opportunité pour ancrer les activités de pharmacie clinique dans le parcours des patients atteints de cancer.

The ten-year cancer control strategy launched in 2021 highlights the structuring of supportive care as a strong axis to limit the side effects of treatments and simplify the patient's journeys. On the other hand, the "Gradation instruction" published in 2020, introduced new invoicing rules for outpatient hospital wards, which facilitates the coordinated interventions of several health professionals (medical, paramedical, or socio-educational) around patients. Among these professionals, the pharmacist has a particular role, inside the multidisciplinary oncology teams, since cancer oral therapies require therapeutic adherence and a continuum of care with retail pharmacists. Until now, these clinical pharmaceutical activities, which include carrying out medication reviews, developing personalized pharmaceutical plans and conducting pharmaceutical interviews with patients, have struggled to develop in a sustainable manner due to a lack of funding in hospitals. Finally, the "gradation instruction" represents a real opportunity to support clinical pharmacy actions, particularly in outpatient hospital wards. In order to save time for hospital teams wishing to initiate or consolidate these activities, we should consider points of vigilance and facilitating factors.

[Medication reconciliation on admission: One year of practice in health care institutions during the COVID-19 pandemic]. / Conciliation médicamenteuse à l'admission : bilan d'une année d'activité en établissement de santé durant la crise COVID-19.

OBJECTIVES: Medication reconciliation is a key point of the v2020 certification. The main objective of this study was to evaluate this activity over one year, including the first epidemic wave at COVID-19. The secondary objectives were to identify the obstacles and levers and to evaluate doctor satisfaction. METHODS: This was a retrospective study of drug reconciliations performed on admission during 12 months of the emergence of COVID-19. Patients aged 65 years and older from orthopedic and visceral surgery, acute hospitalization and conventional medicine units were included. Unintentional discrepancies were analyzed. The obstacles and levers were identified by means of a focus group. Doctors' satisfaction was collected using online quiz. RESULTS: A total of 760 patients were conciliated, of which 27% (n=208) by hospital pharmacy technicians. A decrease in activity was observed during the first epidemic wave. An unintentional discrepancy was found in 77% of patients, and only 48% were corrected by the prescriber. These results were impacted by the pandemic. The pharmaceutical team was mobilized in the logistical management of the crisis, but it was able to adapt in order to perpetuate the activity. Doctors are satisfied with the process. CONCLUSIONS: Medication reconciliation on admission is essential for the prevention of iatrogeny, particularly with the impact of the COVID-19 pandemic in healthcare institutions.

[Optimal pain management for cancer patients with chronic renal failure]. / Spécificités de la prise en charge la douleur du cancer chez l'insuffisant rénal chronique.

The management of multimorphic cancer pain is a major supportive care in oncology, for which many national and international recommendations have recently been updated. Any cancer patient must benefit from access to supportive care from the diagnosis, throughout the entire care pathway. Chronic renal failure, from any etiology, requires special attention and constant attention to details from interdisciplinary caregivers' teams to propose the best analgesic therapeutic strategy, combining complementary and interventional approaches to treatments. Analgesic therapies, in particular opioids and antineuropathics, require specific precautions. A therapeutic alliance integrating clinical pharmacy as a supportive care in its own right, is a major asset allowing the optimization and securing of analgesic drug treatments, conditioning both their efficacy, their tolerance and therapeutic observance, in the goal of improving the patient's quality of life.

[Medication reconciliation: Interests and limits]. / Conciliation médicamenteuse : intérêts et limites.

Admission to hospital is a critical transition point for the continuity of care in medication management. Medication reconciliation can identify and resolve errors due to inaccurate medication histories. The practice of medication reconciliation is securing for the patient because of the medication errors detected with significant clinical impact. Its implementation must comply with the recommendations of the French National Authority for Health (HAS) and its deployment is now integrated into the contract for improving the quality and efficiency of care (CAQES). However, although it allows to intercept medication errors, its impact on the length of hospitalization, the rate of readmission and/or death following discharge seems limited. Given the limited human resources to carry out this time-consuming activity, patient prioritization should be considered. Studies on the fate of patients and on the medico-economic issues are also necessary in order to make this activity sustainable.

[Development of a methodological guide on the implementation of a pharmaceutical decision support system: Feedback from a French university hospital]. / Élaboration d'un guide méthodologique sur l'implantation d'un système d'aide à la décision pharmaceutique : retour d'expérience d'un centre hospitalier universitaire français.

OBJECTIVE: Develop a methodological guide on the implementation of a PDSS (pharmaceutical decision support system). METHOD: Observational study, retrospective conducted at Lille University Hospital from May 2017 to December 2020, corresponding to the period of implementation and then use of the software. The different phases of the project are described as well as the methodology at each stage. RESULTS: Four stages seem necessary for the establishment of the PDSS: reflection and preparation of the project, contracting, implementation, use and evaluation. Based on these results and our experience, in particular the difficulties encountered, a methodological diagram of the various steps necessary for the implementation of a PDSS is proposed. CONCLUSION: The establishment of a PDSS, especially in the field of clinical pharmacy, is a long multidisciplinary process. Several steps, from project preparation to production start-up are necessary. Planning the different stages is essential for the proper implementation of the SADP so that the installation is as efficient as possible.

[Definition and evaluation of a multidisciplinary patient's pharmacotherapy management method: The pharmaceutical care plan]. / Définition et évaluation d'une méthodologie interprofessionnelle d'optimisation de la pharmacothérapie des patients : le Plan de Médication Partagé.

The implementation of pharmaceutical monitoring as defined by the Council of Europe in its Resolution of March 2020 requires defining for each patient, objectives and a treatment plan, to share, monitor and update them in a manner coordinated, interprofessional and in partnership with the patient. It recognizes the central place of the pharmacist by encompassing all of its clinical pharmacy activities and emphasizes the need for interprofessional collaboration (Hepler CD, Strand LM. Opportunities and Responsibilities in Pharmaceutical Care. American Journal of Hospital Pharmacy. Mars 1990; 47(3): 533-543). This work first presents the pharmaceutical care plan as a multiprofessional methodology that meets the objectives of pharmaceutical monitoring, then in a second step its evaluation through two regional projects. The pharmaceutical care plan unites, around the patient, all the actors involved in their pharmacotherapy, throughout their care path. It makes it possible to control the iatrogenic drug risk and includes the patient's drug management with regard to curative, preventive and palliative objectives and in a global strategy for the care and promotion of patient health. This methodology is integrated into coordinated exercise strategies and care pathway approaches. Several levers will help support its deployment, such as inter-professional education and digital health tools.

[Use of dronabinol in the treatment of resistant neuropathic pain: Feedback from patients followed in a multidisciplinary pain center]. / Utilisation du dronabinol dans le traitement des douleurs neuropathiques réfractaires : retour d'expérience des patients suivis dans un Centre d'évaluation et de traitement de la douleur.

INTRODUCTION: Dronabinol is a drug composed of synthetic delta-9-tetrahydrocannabinol. In France, dronabinol requires a named Temporary Utilisation Authorisation (TUA), for the treatment of refractory neuropathic pain. Few data currently exist concerning its efficacy and tolerance. We present our feedback on its use for chronic pain patients, the multidisciplinary supervision and the monitoring set up by the clinical pharmacist. METHOD: This retrospective monocentric study presents Patients Global Impression of Change and tolerance data from patients treated with dronabinol in a pain center between October 2020 and July 2021. We present their satisfaction towards the care process. RESULTS: Nineteen patients were treated with dronabinol during the study period. - The clinical pharmacist issued 180 advices for patients and doctors. Patients reported a positive impact of the telephone follow-up carried out by the clinical pharmacist. - 75% (n=9/12) of patients who continued treatment for more than 3 months reported improvement in their health. - 74% (n=14/19) of patients had at least one adverse event, six patients needed to discontinue the treatment. DISCUSSION-CONCLUSION: Dronabinol represents an alternative that can improve the quality of life of some patients suffering from refractory neuropathic pain. Nevertheless, as with any medicine, its initiation requires a rigorous evaluation of the benefit-risk balance. The close collaboration between the physician and the clinical pharmacist allows a secure management patients and makes this complex drug circuit easer.

[Clinical pharmacy in four French-speaking university hospitals, integration and supervision of clinical pharmacists: An exploratory study]. / Pharmacie clinique au sein de quatre CHU de la francophonie, intégration et encadrement des pharmaciens cliniciens : une étude exploratoire.

BACKGROUND: Pharmacy practice continues to evolve worldwide. The clinical role of the pharmacists is increasingly recognized and their integration into the health care team is irreversible. Despite this progress, there are still a wide disparity in the scope of practice provided by hospital pharmacists around the world. This disparity can be attributed to a variety of factors. OBJECTIVES: The primary objective is to describe the organization of clinical pharmacy in four university hospitals in four French-speaking countries. The secondary objective is to identify similarities and differences and to identify perspectives for the future. METHODS: This is an exploratory cross-sectional descriptive study. The study targeted a university hospital (CHU) in France, Belgium, Switzerland and Canada (Quebec). A volunteer expert pharmacist involved in the management of clinical pharmacy at each hospital was approached at the initiative of a team member. A working group of five pharmacists was set up. RESULTS: During the year 2021, the group met virtually on ten occasions. Although all institutions have an academic mission, they have very different numbers of beds and volumes of activity. The number of pharmacists is also very different (0.83 FTE pharmacist/1000 admissions in Belgium, 0.22 in France, 0.59 in Switzerland and 2.39 in Quebec). In all countries, pharmacists provide clinical pharmacy services to patients in a centralised or decentralised manner, including, to various extent, prescription analysis, medication reconciliation, pharmaceutical interviews and discharge plans. CONCLUSIONS: Clinical pharmacy practice is very heterogeneous in a selection of four French-speaking teaching hospitals. Identification of similarities and differences may inspire improvements in the organization of clinical pharmacy activity. This work has contributed to the establishment of a community of practice on clinical pharmacy in the French-speaking world.

[Standardized computer recording of clinical pharmacy procedures in health care institution: Feedback and evaluation of potential economic value]. / Enregistrement informatique normalisé des actes de pharmacie clinique en établissement de santé : retour d'expérience et évaluation de la valorisation économique potentielle.

Clinical pharmacy procedures are clearly defined by the French society of clinical pharmacy. However, clinical pharmacists do not have efficient tools for their traceability. This need has increased following the publication of the instruction on the day hospital management of patients. Indeed, the action of the clinical pharmacist is included in it. In order to improve our traceability of clinical pharmacy acts and to take advantage of the implementation of the instruction, we worked with the medical information department to integrate our activity into their business software and to model the pathways valued by the intervention of the clinical pharmacist in outpatient care and in day hospital.

Assessment of insulin adherence in diabetic outpatients: An observational study.

OBJECTIVES: In the management of diabetic patients on insulin therapy, adherence to medication is a key element for avoiding chronic complications. The purpose of this study was to evaluate diabetic patients' ability to translate glycemic results into an appropriate insulin dose and thus, adherence to insulins. METHODS: This was an observational, retrospective, monocentric pilot study. Diabetic patients on insulin therapy being followed at the metabolic and endocrine diseases department were divided into two groups depending on their mode of glycemic control at home: capillary glycemia (Notebook group) or interstitial glycemia using the FreeStyle Libre® flash system (FSL group). Adherence was assessed based on the rate of compliance in adapting insulin doses to the prescribed protocols (depending on type of insulin, glycemic targets, and patients' characteristics) by a pharmacy resident and a senior diabetologist. Good adherence was defined as a minimum rate of 80% of conforming insulin injections for each patient. RESULTS: A total of 50 patients were included, 35 in the Notebook group and 15 in the FSL group. Two-thirds of patients were non-adherent to insulin. Dose adjustment errors mainly concerned rapid-acting insulin with 51.1% of non- conformities, 10.0% of which were due to underdosing in the Notebook group and 21.7% to overdosing in the FSL group. Hyperglycemia was predominant in both populations with a median time in range of 19.0% in the FSL group and well below recommendations (>70%). CONCLUSIONS: Despite the use of increasingly efficient, easy-to-use devices in diabetes monitoring, insulin non-adherence and glycemic imbalance are unresolved major issues. Diabetic patients require reinforced medical follow-up for optimal insulin management.

Impact of the COVID-19 pandemic on drug-related problems and pharmacist interventions in geriatric acute care units.

OBJECTIVES: To assess and compare the pharmaceutical analysis on drug management in a geriatric acute care unit prior to and during the COVID-19 pandemic. METHODS: This was a single-centre, retrospective, and comparative cohort study. All Pharmacist Interventions (PIs) carried out in the unit between 27 January 2020 and 30 April 2020 were distinguished according to whether they were conducted prior to or during the first wave of COVID-19. The main outcome measure was the rate of PIs per patient and per prescription lines analysed. Other data collected were the drug class managed by the PI, the Drug Related Problems (DRP) identified, the nature of the advice given, and the acceptance rate by geriatricians. RESULTS: A total of 355 patients were analysed, with PIs generated for 21.7% of the patients prior to COVID-19, and for 53.4% of the patients during the first wave (p<0.001). Among the 4402 prescription lines analysed, 54 PIs were carried out for prescriptions prior to COVID-19, and 177 during the first wave (p=0.002). DRPs were mostly related to anti-infectious drugs during the pandemic (20.3%, p=0.038), and laxatives prior to the pandemic (13.0%, p=0.023). The clinical impact of the PIs was mainly moderate (43.7%). The acceptance rate was 59.3%. CONCLUSIONS: A greater amount of DRPs were detected and more therapeutic advice was proposed during the first wave of COVID-19, with a focus on drugs used for the management of COVID-19 rather than geriatric routine treatments. The needs for clinical pharmacists were strengthened during the pandemic.

[Evaluation of the training of clinical pharmacy residents in prescription analysis using an ergonomic approach]. / Évaluation de la formation des internes en pharmacie clinique à l'analyse des prescriptions selon une approche ergonomique.

OBJECTIVES: To perform an ergonomic intervention using the methodology of the analysis of the activity of the training process of clinical pharmacy residents in the analysis of prescriptions. METHODS: The evaluation was carried out over two semesters: from May to October 2016 (first study) and from November 2016 to April 2017 (second study). The interviews and observations were conducted by an ergonomist who is an expert in this type of evaluation. The first study was based on observations of the training process and interviews at different time. The second study allowed to support pharmacists and evaluate the changes following the recommendations of the previous study. RESULTS: A total of 6 and 9 residents participated in the first and second study, respectively. During the first study, 6 difficulties were raised which allowed implementation decisions. Feedback from residents on the training process was generally positive for the first part of the training but negative for the last part. The average number of fears expressed by the residents was higher at the beginning (2.9 fears) than at the end (1 fear). CONCLUSIONS: The training process has been adapted to the expectations and feelings of the residents. Follow-up at the beginning and throughout the internship was essential. The next stage of this work will be to evaluate the contribution of the dashboards for monitoring clinical pharmacy skills in the new degree for hospital pharmacy.

[What academic training for pharmacy students for clinical pharmacy? Example of shared medication report]. / Quelle formation académique pour les nouvelles missions de pharmacie clinique à l'officine ? Exemple du bilan partagé de médication du sujet âgé.

OBJECTIVES: In 2018, the implementation of shared medication reports in pharmacy encourages pharmacists to cooperate with other healthcare professionals. This job allows a decrease of medication errors in elderly. This requires a reorganization of the training offered by universities (initial and continuing training). The aim is to present the results of this pedagogical experimentation. METHODS: The experimentation (years 2017-2018 and 2018-2019) required the creation of a course to allow students to carry out a pharmaceutical analysis suitable to elderly people, to set up and carry out a shared medication report in pharmacy. Then, during their 6th year internship, students had to carry out at least one shared medication report per month. A monthly follow-up was organized with a database online. RESULTS: Sixty-four students and 35 internship supervisors participated in the experimentation. All the students improved their ease in using clinical pharmacy tools (pharmaceutical analysis, pharmaceutical interventions, assessment of adherence, etc.). They carried out 345 shared medication reports. In 24.3% of cases, an improvement in the prescription was proposed to the doctor (general practitioner or specialist). For 80% of the internship supervisors, the initial training of the students helped to set up this new pharmacy activity. CONCLUSIONS: This teaching is appreciated by students and internship supervisors. It enabled the adoption of the various tools essential for carrying out shared medication reports in pharmacy. Shared medication reports reinforce the multidisciplinary work of pharmacists, especially with general practitioners.

[Medical reconciliation for hospitalized patients in orthopedic surgery department: Return of experience over 2 years of practice]. / Conciliation médicamenteuse à l'entrée des patients dans une unité de chirurgie orthopédique : retour d'expérience sur plus de 2 ans de pratique.

OBJECTIVES: Some medication errors can be prevented by pharmacist action such as medication reconciliation. The main objective of this study was to evaluate the medication reconciliation activity after two years of practice. The secondary objective was to assess the medical staff's satisfaction following the setting up of the activity. METHODS: This retrospective study was realized over a period of two years in our hospital. Patients meeting the following criteria were included: 65 years and over, hospitalized in orthopedic surgery department, preferentially after a discharge of the emergency room. After the best possible medication history was established, it is compared to medicines ordered. The discrepancies were defined as intended or unintended. Study data were collected and analyzed using Excel and SPSS statistics®. RESULTS: A total of 899 patients met the inclusion criteria during the study period, mean age was 78 years (27; 104). A total of 84 % of our cohort was admitted after a discharge of the emergency room. Seventy five percent of the population had at least an unintended discrepancie, a mean of 2,3 unintended discrepancies per patient was identified. Seventy five percent of the unintended discrepancy were discussed and resolved. The medical staff was mostly satisfied of the activity. CONCLUSION: The medication reconciliation secured the drug management of hospitalized patients.