Discrepancies between electronic prescribing systems and patients' actual use of medicines can result in adverse events and medication errors and have serious consequences for the patients. The discrepancies can be identified when performing a thorough medication reconciliation. Computerized health care systems throughout the Danish health care sector are integrated with the Shared Medication Record (SMR). In the SMR, current medication and medication prescriptions are registered. The aim of this study was to evaluate the number and types of discrepancies between medications listed in the SMR and an updated medication list, obtained through a thorough medication reconciliation, for patients admitted in Danish hospitals. Pharmacists listed the number and type of discrepancies for 412 patients. A total of 1,004 discrepancies were registered, with a mean number of 2.4 medication discrepancies per patient. For 25% (n = 101) of the patients, no discrepancies were found, 20% (n = 86) had one discrepancy, and 16% (n = 66) had five or more discrepancies. More than 50% of the patients had one or more medications in the SMR that the patient did not administer, and 12.6% used medications that were not listed in the SMR. This shows that the SMR should not be used as the only source of information when recording medication history.

In some hospitals, clinical pharmacists review the medication to find drug-related problems (DRPs) in acutely admitted patients. We aimed to identify the nature of identified DRPs and investigate factors of potential importance for the clinical implementation of pharmacist suggestions. In 100 randomly selected medication review (MR) notes, we retrospectively evaluated the clinical implementation and classified (1) timing and communication of the review; (2) DRPs and related suggestions for the physician; and (3) DRPs' potential clinical relevance to patients as 'beneficial', 'somewhat beneficial', 'no relevance' or 'other relevance'. Of 327 DRPs (0-13 DRPs per patient), 42% were implemented. The clinical implementation was higher if the MR note was made prior to (instead of after) the physician's admission, and even higher if the suggestions were communicated verbally (instead of only in writing) to the physicians (44% versus 79%, p < 0.05). The clinical relevance of the DRPs was either 'beneficial' (16%), 'somewhat beneficial' (43%), 'no relevance' (22%) or 'other relevance' (19%). The 'beneficial' DRPs had a higher clinical implementation (53%) than 'no relevance' (34%) (p < 0.05). The most frequently implemented suggestions were based on DRPs concerning 'indication for drug treatment not noticed', 'inappropriate drug form' and 'drug dose too low', with implementation rates of 83%, 67% and 63%, respectively. In our sample, the pharmacist's MR suggestions were only implemented by physicians in 42% of the cases, but review prior to physician contact and verbal communication of the suggestions, higher clinical relevance and specific types of DRPs were associated with a higher implementation rate.

Background Patients poisoned with paracetamol are treated with the antidote N-acetylcysteine (NAC). According to the previous Danish national guidance the first infusion with NAC has to be mixed in 300 ml 5% glucose (or isotonic NaCl). In Denmark 300 ml solutions are only supplied in glass bottles. These are not designed to be used with IV poles. As an alternative 500 ml solution are supplied in infusion bags designed to be used with IV poles. This requires the nurse to withdraws 200 ml of the solution. Pharmacy staff from the Capital Region had been asking the Medicines Information Centre (MIC) whether it was possible to use 250 ml of glucose solution instead of 300 ml. Purpose The task was to investigate the possibility of changing practice when preparing NAC infusions, in order to secure easier, faster and more rational treatment of patients poisoned with paracetamol. Materials and methods Pharmacy staff visiting hospital wards daily had independently been observing the inappropriate and time-consuming preparation of NAC infusions. The MIC was asked to provide a more manageable handling routine in the hospital. The MIC task involved: Reviewing the antidote/emergency management guidelines Reviewing the relevant literature regarding treatment with NAC Discussing the case with the clinical pharmacologist connected to the national Danish Poison Control Hotline. Results The conclusion finally resulted in a change in the national guideline for the treatment of paracetamol poisoning. This change of volume for preparation of NAC infusions further provided additional benefits: faster initiation of treatment improved patient safety due to simpler handling price reduction of approximately 10€ per treatment Conclusions The MIC concluded that 250 ml solution can be used equivalent to 300 ml.