BackgroundThe prescription system known as RELE is the electronic prescribing and dispensing system that has been used by the Balearic Islands Health Service (IB-SALUT, Spain) since April 2006. This repository contains patients’ computerised medication profiles (CMPs). Data from studies conducted in other settings have shown the existence of discrepancies between the medications recorded in patients’ CMPs and the medications actually taken by the patients.MethodsChronic medications recorded in RELE CMPs were compared with those obtained through a structured clinical interview with patients or the persons responsible for the administration of the patients’ medications. A descriptive analysis of each discrepancy was performed. Potentially associated factors were analysed using Pearson’s χ2 test.ResultsOf the 215 CMPs studied, 168 (78%) had discrepancies. The rate of discrepancies in the general population inferred from these results ranged from 72.57% to 83.71%, with a 95% confidence level. Polypharmacy was associated with the presence of discrepancies (χ2: 39.998, 1 df, p<0.0001) as well as patient age >65 years (χ2: 18.949, 2df, p<0.0001) and higher comorbidity (χ2: 12.548, 2 df, p=0.002). The association between the types of discrepancies and their causes showed that prescriber-generated dosage errors were the most common errors (n=116; 27%), followed by patient-generated commissions (n=79; 18%), patient-generated dosage errors (n=77; 18%) and prescriber-generated commissions (n=73; 17%).ConclusionThe rate of discrepancies identified in this study shows that clinical interviews with patients during transitions of care continue to be essential.

Aim and objectives To compare the feasibility and clinical relevance of QT advice guided by the original and adapted QT guideline. Material and methods QT advice provided by the pharmacist was analysed. This retrospective analysis included: number of times QT advice was given according to the original (April 2018 to January 2019) and the adapted guideline (May 2019 to October 2019), number of QT drugs (defined as drugs on the CredibleMeds list KR) per prescription and QTc interval >500 ms (if known). For 1 month (15 May to 14 June 2019), the acceptance rate of the pharmaceutical advice, including the QT advice was registered. Results Differences between the original and adapted guideline are: (1) threshold for advising an ECG (original: !2 prescribed QT drugs or 1 QT drug in combination with a drug that inhibits the metabolism of a QT drug; adapted: !1 prescribed QT drug) and (2) definition of a recent ECG (original: maximum 1 year old; adapted: during hospitalisation). If no recent ECG is available or the QTc interval is >500 ms, advice is given to the physician.The number of times advice was given using the original and adapted guideline were 78 (8 advices/month) and 243 (41 advices/month), respectively. On average, using the adapted guideline, advice related to QTc interval !500 ms was given 5 times per month compared with once using the original guideline. The acceptance rate of QT advice was 40% with an overall acceptance rate of 79% for all pharmaceutical advices. Conclusion and relevance Adapting the QT flow resulted in a fivefold increase in the number of times advice was given in relation to QT. The rather low acceptance rate may be explained by the fact that the pharmacist only selected patients on QT drug prescriptions. To enhance the number of times clinically relevant advice is given, patient related risk factors (hypokalaemia, age, gender, cardiovascular comedications) should be included. It is therefore necessary that personalised risk assessment systems help the pharmacist to identify patients at greatest risk for QT prolongation.

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