Seamless care means providing continuous medication supply for patient and uninterrupted transfer of information about patient’s medication therapy during patient’s transition between different healthcare settings. Medication reconciliation is one of the cognitive pharmaceutical services that are part of seamless care. It is a process that ensures accurate and complete medication information transfer at interfaces of care, with the aim to reduce the occurrence of medication discrepancies.
The purpose of our research was to analyze the process of seamless care performed by clinical pharmacist at patients’ admission to University rehabilitation institute, Republic of Slovenia - Soča. Our goal was to gather information about the frequency of medication discrepancies between medication history and admission orders, classify types of discrepancies, analyze intention and documentation of discrepancies and gather information how often pharmacist’s proposal for discrepancy resolution was accepted. The analysis included patients who were admitted to two chosen hospital wards in the first three months of 2018.
The research included 101 patients, whose average age was 58.0 years. Patients’ medication histories contained 922 medications altogether, of which 388 (42.1 %) had identified discrepancies. 89.7 % of patients with at least one medication in their medication history had at least one medication discrepancy. Medications with the most discrepancies were nervous system medication (eg. analgesics, psycholeptics) and alimentary tract and metabolism medication (eg. drugs for constipation, drugs for acid related disorders). Most frequently classified types of discrepancy were drug omission (36.3 %), dosage change (31.2 %) and drug addition (24.2 %). 33.5 % of all discrepancies were intentional and documented, 16.5 % intentional and undocumented, 16.8 % unintentional and 33.2 % unspecified. Pharmacist’s proposal for discrepancy resolution was accepted in 19.9 % of unintentional and unspecified discrepancies.
Results of our research show the process of seamless care at admission to University rehabilitation institute, Republic of Slovenia - Soča as positive and useful. However, it is important to strive for even better quality of seamless care and medication reconciliation practice, with close cooperation of all involved healthcare professionals.