4CPS-256 Discharge medication reconciliation: evaluation of a 7-months activity

Background Since March 2016 a discharge pharmaceutical care system was developed in an internal medicine ward (30 beds) from Monday to Friday, in addition to an admission medication reconciliation (MR), already performed. This activity is conducted in three steps: discharge MR treatment plan performed with patient and pharmaceutical interview with patient or/and his family. Purpose The objective is to evaluate this new pharmaceutical activity. Material and methods This retrospective study was conducted from July 2016 to February 2017. All patients leaving the unit were included while prioritising patients returning home. Deceased patients and transferred patients to another acute unit have been excluded. Collected information were age and sex of patient, number of MR, interviews and treatment plans, causes of non-reconciliation and medication discrepancies. Results Among 396 admitted patients, 322 patients were eligible for discharge MR (23 deaths, 51 transfers). The average age is 72.3 years and (sex ratio 0.9). On these eligible patients, 207 MR (64.3%), 193 treatment plan (59.9%) and 148 pharmaceutical interview (46%) were done. Reasons for non-conciliation were absence of pharmacist at patient discharge (66%) and transfer to rehabilitation establishment (44%). A continuity of care from hospital to community pharmacy has been required for 10.6% of patients. Two hundred and fifty-one medication discrepancies were observed as part of 121 discharge prescriptions and less than 5% are considered potentially serious. In average a discharge prescription had two medication discrepancies (0–7). The most frequently encountered were omissions of treatment started during hospitalisation (19.5%), treatment optimisations (17.5%) and former treatments stopped during hospitalisation because they are not available in our hospital and are not taken back (14.7%). 97.5% of these have been corrected after pharmacist intervention. At least all of the patients who received a discharge from pharmaceutical care had discharge MR. Most of them received a treatment plan and almost three-quarters had pharmaceutical interviews except for mentally ill people and retirement home’s patients. Conclusion Structured discharge and coordination between all team involved (medical, pharmaceutical and administrative) are essential to improve this new activity. No conflict of interest