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).