Evaluation of the medication reconciliation process and classification of discrepancies at hospital admission and discharge in Italy

Background Medication errors at different transitions of care are common and potentially harmful. Medication reconciliation process should be evaluated to reduce the unintentional discrepancies. Objective This study aims to identify and classify unintentional medication discrepancies at hospital admission and discharge and associated risk factors. Setting Two general internal medicine and a pulmonology wards of an Italian non-academic hospital. Method A retrospective observational study was conducted among adult patients admitted to the wards. In order to evaluate the current medication reconciliation process of these wards, the frequency and type of unintentional chronic medication discrepancies between the physician assessment of home medication and hospital admission and discharge prescriptions were studied. Patients’ characteristic associated with the presence of at least one unintentional discrepancy were evaluated. Main outcome measure Frequencies of unintentional medication discrepancies upon admission and discharge and associated patients’ characteristics. Results Among the 144 patients enrolled in the study, 53 and 64 unintentional medication discrepancies were identified at hospital admission and at discharge, respectively. Both at admission and discharge a quarter of patients had at least one unintentional discrepancy. ‘Medication omission’ was the most frequent type of discrepancy identified and respiratory system and nervous system were the classes of medication with the highest rate of unintentional discrepancies. Unintentional discrepancies were more likely to occur in patients receiving more medicine pre-admission, longer hospitalization stays and coming from or discharged to a nursing home. Conclusion Transitions of care are critical moments for patient safety in terms of unintentional medication discrepancies and a more structured medication reconciliation process is needed. The medication reconciliation process should be considered in terms of a multidisciplinary approach involving all health professionals as well as patients and caregivers directly.