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Assessment of the medication reconciliation process conducted at admission to an internal medicine ward: The frequency and type of remaining discrepancies identified with a pharmacist intervention
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmaceutical Biosciences.
2015 (English)Independent thesis Advanced level (degree of Master (One Year)), 10 credits / 15 HE creditsStudent thesis
Abstract [en]

Abstract (ESCP)

Title: Assessment of medication reconciliation process: Effect of a pharmacist intervention.

Author: Eva María Pálsdóttir

Supervisor: Maria Danell Möller, Clinical Pharmacist at Danderyd Hospital

Examiner: Elisabet Nielsen

Institute: Uppsala University, Uppsala, Sweden

Background and objective: Discrepancies in medication lists at hospital admission are common and a well-known problem. The objective was to describe with a pharmacist conducted medication reconciliation; the frequency of discrepancies in medication lists of admitted patients at an internal medicine ward. Another objective was to analyze the types of discrepancies and to classify them according to the Anatomic Therapeutic Chemical classification system. Furthermore to evaluate the effects and results of a pharmacist intervention.

Design: Descriptive study. Admitted patients had an updated medication list from the Emergency Department. At admission to the ward, patients received nurse conducted medication reconciliation. Within 24 hours a pharmacist conducted medication reconciliation to identify the patient´s most accurate medication list. This was done by comparing the acquired list with the prescribed medications in the hospital Electronic Medical Record and retrospectively looking for documented reasons for discrepancies. The discrepancies identified were categorized by type and drug class.

Descriptive statistics and specific tests were used for analysis.

Setting: The study was carried out at Danderyd Hospital Stockholm, Sweden, April-May 2015.

Main outcome measures: Number and frequency of discrepancies according to type identified by a pharmacist.

Results: The study included 75 patients. At least one discrepancy was identified for 40 of these patients (53%). 33 patients did not receive medication reconciliation by admitting nurse and identified discrepancies were slightly more common for these patients (55%). However, the association was not statistically significant (p=0.85). The most common type of discrepancy was additional medication (42%) and wrong dose (25%). The most frequent drug class associated with medication discrepancies was Alimentary Tract and Metabolism.

Conclusions: Over half of the patients were identified with discrepancies regardless of an updated medication list at Emergency Department and medication reconciliation performed by admitting nurse or not. It is important to implement a structured approach to minimize discrepancies in patient’s medication lists and a pharmacist can be well suited for the role. 

Place, publisher, year, edition, pages
2015. , 16 p.
Keyword [en]
Medication reconciliation, pharmacist intervention, discrepancies, medication lists
National Category
Pharmaceutical Sciences
URN: urn:nbn:se:uu:diva-270530OAI: oai:DiVA.org:uu-270530DiVA: diva2:889971
Educational program
Master Programme in Clinical Pharmacy
Available from: 2016-09-12 Created: 2015-12-29 Last updated: 2016-09-12Bibliographically approved

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