Medication reconciliation for internal medicine inpatients: collaboration between clinical pharmacists and internists


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Medication reconciliation for internal medicine inpatients: collaboration between clinical pharmacists and internists
Titre de la conférence
Primary and Hospital Care
Le Bloc h F., Rossier C., Dunner S., Matthys V., Widmer N., Blanc A.-L.
6. Frühjahrskongress der Schweizerische Gesellschaft fü Allgemeine Innere Medizin (SGAIM).
Lausanne, Switzerland, June 1-3, 2022
Statut éditorial
Date de publication
Background: Transition of care is a challenging step at hospital discharge especially regarding medication safety. Medication reconciliation (MedRec) is essential to prevent adverse drug events. MedRec consists of comparing the medication a patient has been taking regularly to the new medication list prescribed, to identify and resolve any discrepancies before hospital discharge.
Objective: To implement a MedRec program in an Internal Medi- cine department of a regional hospital (114 beds).
Method: This MedRec program was implemented in November 2020 thanks to extra-funding from the RSHL. The program is divided in 3 components:
1. To standardise medication information among all hospital discharge documents (medications order, discharge letter, discharge treatment plan).
2. To develop a continuous education course on this topic for all internal medicine residents
3. To implement a MedRec intervention involving clinical pharmacists focused on polymedicated patients (≥ 5 drugs prescribed).
Results: This program currently allows the following changes in the department:
1. Discharge prescription orders is now systematically edited as a discharge treatment plan, involving a specific list of “medication stopped during hospital stay”, useful for patients, general practitioners, community pharmacists and in-home nurses.
2. Every 3 months, a dedicated course on MedRec and medication discharge issues is dispensed to all medical residents. This course has been scheduled 3 times in 2021.
3. A prospective follow-up is performed by a clinical pharmacist every working days. MedRec interventions have been performed in 480 patients between 27 Sept. and 31 Dec. 2021; mean of 6.9 patients/day (min 1-max 17). 1131 interventions were addressed to the medical residents; mean of 3 interventions/patient (min 1-max 9). 22% of patients had no intervention.The time spent by the pharmacist corresponded to a mean of 1.6h/day (min: 0.3h-max: 4.4h).
Conclusion: This interdisciplinary project allows to harmonize medication information transmitted to all caregivers involved in the patient management by providing a structured discharge treatment plan. It enhances the awareness of discharge medication problematic among physicians of the Internal Medicine Depart- ment by continuing education courses and regular phone calls from clinical pharmacists. In the future, the challenge will be the sustainability of this program (additional resources needed for MedRec interventions).
Création de la notice
11/08/2022 17:54
Dernière modification de la notice
12/08/2022 5:40
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