The purpose of medication reconciliation (MR) is to provide accurate and complete information on medication treatment when switching between different levels of healthcare. The aim of our research was to prove the importance of the introduction of the MR at hospital admission and discharge in everyday clinical practice. For this purpose, we included 100 patients in the study. They were treated at the Department of Nephrology, Division of Internal Medicine, University Medical Centre Maribor in the period between March and November 2019. In the control group with 50 patients the MR service was performed only at admission. Also in the intervention group 50 patients were included, but the MR service was provided upon admission and discharge when patients also received a personal medication list.
The median age of the included patients was 79 years and 61% of them were women. There were not significant differences between the control and intervention groups in gender, age, and therapy at admission and discharge. They differed significantly only in the glomerular filtration rate at admission, which, in our opinion, did not affect the results of the study. At admission patients received an average 7 medications for regular therapy (range 0–18) and 1 as needed medication (range 0–7). 42.2% of the medications for regular therapy were from the ATC group C.
At admission, at least one intentional undocumented or unintentional discrepancy was present in 44.0% of patients. A total of 78 such discrepancies were identified in 845 medications (9.2%). There were significantly fewer discrepancies in the intervention group than in the control group (p = 0.009), mainly due to the absence of intentional undocumented discrepancies. Based on this, we can conclude that during the study medical staff documented all intentional changes in therapy more consistently. The most common discrepancies at admission were unintentionally omitted medication (41.0%) and unintentionally incorrect dose (20.5%) in regular therapy and intentional undocumented omission of the regular medication (16.7%). The portion of discrepancies was the highest in the medications from ATC group C (38.5%).
At discharge, the percentage of patients with at least one discrepancy was slightly higher than at admission (65.0%). In the control group, we detected 97 such discrepancies (24.4% of all medications) while in the intervention group there were only half as many, namely 50 (11.2% of all medications). A significantly lower number of discrepancies in the intervention group compared to the control group is mainly the consequence of the lower number of unintentional discrepancies in the intervention group. The most common discrepancies at discharge were unintentionally omitted as needed medication (27.9%), intentional undocumented omission of regular medication (21.1%), and intentional undocumented dose adjustment of regular medication (16.3%). Due to as needed therapy, the portion of discrepancies was the highest in the ATC group N (34.5%), followed by groups C (23.6%), A (15.5%), and R (10.8%).
Only 3% of patients had no change in chronic therapy at discharge. We detected a total of 429 changes in patients’ therapy (range 0–12 per patient). The high portion of changes in chronic therapy, together with the significantly smaller number of discrepancies in the intervention group compared to the control group at admission and discharge, are obvious indicators that the introduction of the MR is necessary also in other departments of the University Medical Centre Maribor. It would be reasonable to develop a standard operating procedure that would guide clinical pharmacists through the MR process, unify their work, and enable even better results.