Background During care transitions, discrepancies and medication errors often occur, putting patients at risk, especially older patients with polypharmacy. Objective To assess the results of a medication reconciliation and information programme for discharge of geriatric patients conducted through hospital information systems. Setting A 1300-bed university hospital in Madrid, Spain. Method A prospective observational study. Geriatricians selected candidates for medication reconciliation at discharge, and sent an electronic inter-consultation request to the pharmacy department. Pharmacists reviewed the medication list, comparing it with electronic prescriptions, medication previously prescribed by primary care physicians and other medical records, and resolved any discrepancies. An individualized and tailored drug information at discharge sheet was sent to geriatricians and made available to primary care physicians. Main outcome measure The number and type of discrepancies, the number, type and severity of errors, and the main pharmacological groups involved. Results Medication reconciliation was performed for 118 patients with a mean age of 87 years (SD 5.9), involving a total of 2054 medications, or 17.4 per patient. Discrepancies were found in 723 (35 %) drugs, 105 of which were considered medication errors (15 %); 66 patients (56 %) had at least one error. This gave 0.9 reconciliation errors per patient reviewed and 1.6 per patient with errors. Of the 105 errors, 14 (13 %) were considered serious. The most frequent errors were incomplete prescriptions (40 %) and omissions (35 %). Conclusion An electronic medication reconciliation programme helps pharmacists detect serious medication errors in frail elderly patients and provides complete and up-to-date written information to prevent additional errors at home.

and public hospitals, inside hospital pharmacies and at the patient's home. The Recommendation is to protect patients needing anticancer drug treatments. Highlight: the hospital should provide working instruments and develop a procedure including all instructions for proper anticancer drug management. They also have to: draw up a Patient Safety Training Plan, promote communication and integration among health professionals, provide accurate and complete information to patients and their families, consider the psychological and emotional state of patients and give detailed indications for the delivery of drugs at discharge. Conclusions The Recommendation is a reference for health professionals involved in handling anticancer drugs, providing information about the patient's objectives and expected benefits from treatment. The document provides guidance aimed at preventing errors that can occur during anticancer drug treatment and includes recommendations encouraging the promotion of clinical governance. A verification of this Recommendation is expected soon. Many experts gave their suggestions to facilitate its implementation. No conflict of interest. Reconciliation and dRug infoRmation to geRiatRic Polymedicated Patients at dischaRge using infoRmation technology

BackgroundThe use of STOPP/START criteria is part of the daily routine during pharmaceutical validation. One important pharmaceutical intervention is to recommend digoxin dose adjustment in elderly patients when it is prescribed 0.25 mg/day. Digoxin is a high risk medication; therefore, its correct use is important to prevent serious harm to patients.PurposeTo analyse the impact of pharmaceutical interventions related to digoxin dose adjustment in elderly patients.Material and methodsPharmaceutical interventions recorded between January and June 2015 in a university tertiary hospital were analysed. Recommendations regarding digoxin dose adjustment in patients aged over 75 years with 0.25 mg prescribed were selected. The following variables were measured: patient age, digoxin dose, dose reductions, intervention acceptance, changes in frequency of administration, digoxin substitutions and consequences of unchanged prescriptions.ResultsThere were 77 collected pharmaceutical interventions concerning digoxin dose adjustment in elderly patients. Average patient age was 86.2 (SD 5.7) years. After pharmacist recommendation, 63 (81.8%) prescriptions were modified: 53 (84.1%) suffered 50% dose reduction, 5 treatments were changed from daily to 5 or 6 days a week and 5 other treatments were substituted for carvedilol, bisoprolol or diltiazem. In relation to the 14 (18.1%) unchanged prescriptions, 12 had no negative consequences registered during the study period, but one digoxin prescription had to be reduced to 0.06 mg by the primary care physician and one last patient suffered digitalis toxicity.ConclusionPhysicians are increasingly conscious about the need for digoxin dose adjustment in elderly patients. This has been confirmed by the high rate of recommendation acceptance obtained. The fact that at least one case of digitalis toxicity occurred, reinforces the importance of applying this criterion.References and/or AcknowledgementsFilomena Paci J, García Alfaro M, et al. [Inappropriate prescribing in polymedicated patients over 64 years-old in primary care], Aten Primaria 2015;47:38-47 (Spanish)No conflict of interest.