What is known and Objective: There is no optimal standardized model in the transfer of care between hospitals and primary healthcare facilities. Transfer of care is a critical point during which unintentional discrepancies, that can jeopardize pharmacotherapy outcomes, can occur. The objective was to determine the effect that an integrated medication reconciliation model has on the reduction of the number of post-discharge unintentional discrepancies. How to cite this article: Marinović I, Bačić Vrca V, Samardžić I, et al. Impact of an integrated medication reconciliation model led by a hospital clinical pharmacist on the reduction of post-discharge unintentional discrepancies.
BackgroundThe need for dose adjustment in patients with renal impairment is well known. Despite globally implemented interventions for improvement in dose adjustment, there is dazing noncompliance to dosing recommendations in renal impairment, which came into focus in the 21 st century.PurposeTo determine the degree of drug dose adjustment in hospitalised patients with renal impairment, frequency and type of drugs that need to be adjusted with regard to creatinine clearance (CrCl). To assess the acceptance rate of the clinical pharmacist interventions addressed to doctors.Material and methodsProspective interventional study was conducted at the Department of Internal Medicine during a 3 month period. Using the Cockroft–Gault equation, patients with renal impairment were identified at admission and their pharmacotherapy were reviewed daily. Prescribed drugs which required dose adjustment in renal impairment were classified as adjusted or unadjusted. For the latter, written pharmaceutical intervention was sent to the concerned doctor.ResultsAlmost one-third of all admitted patients had CrCl <60 mL/min at admission. Three hundred and nine patients were included in the study, with 99 (32%) patients having at least one unadjusted drug. Out of 514 prescriptions which required dose adjustment 148 (28.5%) were not adjusted. Patients with CrCl <15 mL/min and those who died had the highest percentage of unadjusted drugs, 53% and 44%, respecitvely. The C group of drugs and the J group had the most of the total number of unadjusted prescriptions with 55% and 29%, respectively. The highest proportion of drugs not in agreement with the recommendations were within the J group with 52%, and they were followed by the C and A group, with 33% each. Overall, 123 pharmaceutical interventions were made, out of which 50 (40.6%) were accepted and 73 (59.4%) were unaccepted. Twenty-five interventions were not sent, which totals 16.9% of the total number of improperly dosed drugs.ConclusionNearly every third admitted patient had impaired renal function. Frequent dose unadjustments increase the risk of adverse drug reactions. Clinical pharmacists can increase the rate of proper dose adjustments in patients with renal impairment. The implementation of systemically provided pharmaceutical care in hospital wards can facilitate positive treatment outcomes and increase patient safety.References and/or AcknowledgementsMany thanks to Professor Vesna Bačić VrcaNo conflict of interest
Transfer of care is a sensitive process, especially for the elderly. Polypharmacy, potentially inappropriate medications (PIMs), drug-drug interactions (DDIs), and renal risk drugs (RRDs) are important issues in the elderly. The aim of the study was to expand the use of the Best Possible Medication History (BPMH) and to evaluate polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs on hospital admission, as well as to determine their mutual relationship and association with patients’ characteristics. An observational prospective study was conducted at the Internal Medicine Clinic of Clinical Hospital Dubrava. The study included 383 elderly patients. Overall, 49.9% of patients used 5–9 prescription medications and 31.8% used 10 or more medications. EU(7)-PIMs occurred in 80.7% (n = 309) of the participants. In total, 90.6% of participants had ≥1 potential DDI. In total, 43.6% of patients were found to have estimated glomerular filtration rate < 60 mL/min/1.73 m2, of which 64.7% of patients had one or more inappropriately prescribed RRDs. The clinical pharmacist detected a high incidence of polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs on hospital admission. This study highlights the importance of early detection of pharmacotherapy problems by using the BPMH in order to prevent their circulation during a hospital stay. The positive correlations between polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs indicate that they are not independent, but rather occur simultaneously.
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