BackgroundReconciliation errors (RE) represent a security problem and have been identified by organisations such as the Institute for Healthcare Improvement (IHI) and the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) as a priority issue within security strategies for patients.PurposeTo determine the incidence of RE in polymedicated elderly patients admitted to a trauma service and to analyse the type of RE, drug group involved and severity of the RE.Material and methodsProspective observational study conducted between June and September 2015, in which all patients aged 65 years or older on treatment with at least 5 drugs were included. Variables collected were: age, sex, drugs prescribed, RE and severity of RE. The information sources used were electronic clinical and prescribing records and patient interview. Patients were included in the first 24 h after admission. Chronic medication list was collected by consulting the information sources mentioned above. This list was compared with prescriptions performed during hospitalisation. In cases where a discrepancy that required clarification was found, it was discussed with the doctor. To classify a discrepancy as an RE, the prescriber had to accept it as such after seeking clarification.Results67 patients were included with a mean age of 69 years (29.7% men, 70.3% women). 577 drugs were reviewed, resulting in an average of 8.46 medications prescribed per patient with an average of 2.88 RE per patient. The most common RE was omission of drugs (74.09%) followed by different dose, regimen or route (6.14%). According to the Anatomical Therapeutic Chemical Classification level 4, the main groups involved in the RE were benzodiazepines with 15.03% of the RE, HMG Co-A reductase inhibitors (5.23%) and cardioselective beta blockers (4.58%).Regarding the severity of errors, 73.21% reached the patient without damage, 14.59% reached the patient and required monitoring and 12.20% missed the patient. The recommendation made by the pharmacist was accepted in 81.3% of cases.ConclusionThe most common RE was drug omission. The pharmacist has a key role in collecting the best possible medication history from the patient to avoid these RE. Medication reconciliation emerges as an opportunity to establish the role of the pharmacist in the health system, to redefine the doctor-pharmacist-patient relationship and to improve the use of medicines and treatment outcomes.No conflict of interest.
BackgroundAt least 50% of patients admitted to hospital for surgery take medicines to treat chronic diseases. Some medicines may interact with drugs used during surgery, but there are few situations that contraindicate this use. Most drugs must be maintained in the perioperative period, administering the last dose 2 h before surgery and restoring with oral intake. Others must be stopped, replaced or temporarily administered by another route. Heightened awareness and diligent documentation of patient medications from admission to discharge can reduce serious problems in the perioperative period.PurposeTo implement an evidence based protocol for managing chronic medication in the perioperative period.Material and methodsAn anaesthesiologist, orthopaedic surgeon and two hospital pharmacists formed the multidisciplinary team. A Pubmed search was performed using the following terms: perioperative, chronic, medication and management. Studies were reviewed and a protocol with management recommendations before surgery, surgery day and after surgery was made. A guide in book form was developed and distributed by the surgical services.Results13 articles and some evidence based guidelines with strength therapeutic recommendations were reviewed. Drugs reviewed were grouped into 9 blocks as the system on which they act, and on this basis, management recommendations were established. A section of herbal medicines with specific recommendations for those for which there is increasing evidence were included. 58 therapeutic groups were reviewed according to ATC classification level 3. Of these, 53.4% were recommended to continue treatment, 8.6% to assess according to clinical status and 38% to discontinue. It was generally recommended to discontinue therapy with: cyclooxygenase-1, -2 inhibitors, cyclophosphamide, immunosuppressives, biologics, antihyperuricaemic drugs, potassium supplements, diuretics, fibrates, haemorheologics, new oral anticoagulants, hormone replacement therapy, oestrogen modulators, bisphosphonates, systemic hormonal contraceptives, oral hypoglycaemic agents, monoamine oxidase inhibitors, lithium, phosphodiesterase inhibitors, vitamins and nutritional supplements. Herbal medicines are recommended to discontinue 7–10 days before surgery.ConclusionEpidemiological studies on the management of perioperative drugs are heterogeneous. It is recommended to continue treatment with most drugs but information does not come from clinical trials, but expert opinion, case reports or theoretical considerations. While for some drugs there are good consensus recommendations, for others the available information is limited or controversial; which leads to the coexistence of several trends in clinical practice.No conflict of interest.
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