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J Am Geriatr Soc. 2013 Aug;61(8):1262-8. doi: 10.1111/jgs.12380. Epub 2013 Jul 19.

Effect of medication reconciliation on unintentional medication discrepancies in acute hospital admissions of elderly adults: a multicenter study.

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Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, the Netherlands.



To investigate the effect of pharmacy-based medication reconciliation on the frequency of unintentional medication discrepancies in acutely admitted individuals aged 65 and older.


Multicenter intervention study with pre-post design.


Twelve Dutch hospitals.


One thousand five hundred forty-three individuals aged 65 and older with an acute hospital admission through the emergency department.


The intervention consisted of the Best Possible Medication History (BPMH), based on combining information from the community pharmacy record, the information provided by a structured interview with participants about their medication use, and medication containers. In nine hospitals, pharmacy technicians obtained the BPMH, and in three hospitals, a mixed model was used (physicians or pharmacy technicians obtained the BPMH). Primary outcome measure was the proportion of participants with one or more unintentional medication discrepancies. The primary outcome measure was stratified according to type of intervention (pharmacy based vs mixed model).


The proportion of participants with one or more unintentional medication discrepancies was reduced from 62% to 32% [odds ratio (OR) = 0.29, 95% confidence interval (CI) = 0.23-0.37]. These results remained statistically significant after adjustment for type of department and hospital (OR = 0.20, 95% CI = 0.15-0.26), and this effect remained stable for 6 months. Stratified analysis showed that no effect from the intervention was evident in the three hospitals with a mixed-model intervention, in contrast to the hospitals with a pharmacy-based intervention. The medication discrepancy types "omission" and "dosage or strength" occurred most frequently and were the main types that the intervention influenced.


Pharmacy-based medication reconciliation leads to a substantial reduction in medication discrepancies in acutely admitted elderly adults.


medication reconciliation; medication safety; pharmacy-based

[Indexed for MEDLINE]

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