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Int J Clin Pharm. 2016 Aug;38(4):838-47. doi: 10.1007/s11096-016-0292-7. Epub 2016 Apr 2.

Medication at discharge in an orthopaedic surgical ward: quality of information transmission and implementation of a medication reconciliation form.

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Service de Pharmacie, Assistance Publique des Hôpitaux de Paris, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92140, Clamart, France.
Service de Pharmacie, Assistance Publique des Hôpitaux de Paris, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92140, Clamart, France.
Service de chirurgie orthopédique, Assistance Publique des Hôpitaux de Paris, Hôpital Antoine Béclère, 92140, Clamart, France.


Background Medication reconciliation (MedRec) at discharge is a cumbersome but necessary process to reduce the risk of medication errors at transitions of care. The main barriers to implementing such a process are the large number of professionals involved and a lack of collaboration among caregivers. Objective This study was designed to assess the need for a medication reconciliation form at discharge in an orthopaedic surgical ward. Setting The study was conducted in the orthopaedic surgery ward among inpatients at a 407-bed French teaching hospital. Method We first performed a retrospective audit to evaluate the quality of discharge medication information in the medical record, after which a 5-week prospective study was conducted in 2013. All patients admitted to the orthopaedic surgery unit who had at least two chronic diseases and three medications underwent MedRec at discharge. We designed a Best Possible Medication at Discharge List (BPMDL) to be completed by hospital staff and transmitted to community caregivers. Mean outcome measures We assessed the completeness of medication information in the medical records, discrepancies between medications noted on the BPMDL and those prescribed on the discharge order, and the value of the BPMDL for stakeholders. Results Thirty patients were included in the study. Only 4 % of medical records contained a discharge summary with complete medication information. In 67 % of cases, treatment discontinuations at admission were justified, and medications were reintroduced before discharge, while 107 treatments (45 %) were added but not prescribed on discharge orders. Discontinuations prior to discharge were justified in 60 % of cases (treatments were ended or supportive treatment was required during hospitalization). An average of 2.1 treatments were prescribed on discharge orders (vs. 9.4 prescribed on the BPMDL). Patients, general practitioners (GP), and physicians in long-term care settings (PLTCS) rated the format, content, and readability of the BPMDL as satisfactory, and it was found to be of value for patients and PLTCS to support medication information. Because of the very low response rate among GP (10 %), we were unable to determine their satisfaction with the MedRec discharge process. Conclusion The transmission of patient medication information at discharge is often lacking. As such, the BPMDL appears to have value to both patients and community health providers. Because this study was conducted within a single surgical unit, further study in other surgical wards is needed to assess generalizability.


France; Hospital discharge; Medication reconciliation; Orthopaedic surgery

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