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SAT0638-HPR Close The GAP – Medication Discrepancies Revealed by Medication Reconciliation
  1. L. Damlien1,
  2. K.K. Viktil1,2,
  3. E. Røssum-Iversen3,
  4. C.L. Olsen3,
  5. L. Bergmann3,
  6. T. Borgen3
  1. 1Hospital Pharmacy, Diakonhjemmet Hospital Pharmacy
  2. 2School of Pharmacy, University of Oslo
  3. 3Department of Rheumathology, Diakonhjemmet Hospital, Oslo, Norway


Background Studies have shown that 60-70% of patients have medication discrepancies (MD) between medication charts at hospital admission and what the patients are actually taking. These discrepancies could influence treatment and diagnosis. Medication reconciliation (MR) – which is a systematic process including a checklist and a structured interview of the patient – is recognized as a method to obtain a correct list. In Norway the patient are not used to bring their own medicines, even to elective hospital admissions. Most patients do not bring their medication list either. At our department there is no standard procedure for the quality assurance of obtaining the medication list.

Objectives To implement the process of MR at the department of rheumatology.

Methods An interdisciplinary team consisting of nurses, clinical pharmacists, rheumatologists, and a GP was established. A patient representative was also involved in a pilot for MR at the hospital. Multiple initiative were introduced: the patient was asked in the referral letter to bring his/her own updated complete medication list, the electronic patient journal's template for medication list both in the admission note and in the discharge note were revised to clarify medication changes during the stay, and the nurses were especially trained by the pharmacist in the process of MR. In the one year study period all elective patients were asked at admission if they had brought their medication list. MDs between the list obtained by the structured interview and the medication chart obtained by the physician at admission were discussed with the rheumatologist in charge. The rheumatologist adjusted the medication chart at her/his appraisal and eventually the medication list was complete. The extent and type of MDs were registered during a 6-month period (March-September). The quality of the medication information in the discharge note was assessed according to a predefined scale developed by the Norwegian National Patient Safety Program, In safe hands 24-7, (1-12 points 12 being the best) with regard to completeness of medication information (name, strength, dosage, route of administration), indication, dose escalation/reduction, discontinuation, commencement of a new drug.

Results From January to December 2014, 252 (37%) of the elective patients brought their own medication list at admission. In this 12-month period MR was performed for 356 patients (both elective and acute patients), 41% of the total admissions. During the 6-month registration period a total of 417 MDs were revealed for 133 patients (3.2 per patient), and 89% of the patients had one or more MDs. The most frequent type of MD was omission of a drug. The mean score of quality of the medication information in the discharge note increased from 7.7 at baseline to 8.9 of 12 possible points after one year.

Conclusions It is a challenge to implement MR in daily clinical practice. This interdisciplinary quality assurance task should be highly prioritised, as it showed that the interdisciplinary structured MR increases the quality of the medication list which is important with regard to further assessment and treatment of the patient, especially when changing level of care.

Disclosure of Interest None declared

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