4CPS-382 Impact of a clinical pharmacist at transition of care: a prospective study in an orthopaedic ward of a regional hospital

Background and importance Transition of care (TOC) is a high risk period for medication errors. Discrepancies and incomplete medication information are common on hospital admission and discharge, potentially leading to drug related problems and adverse drug events at TOC. Aim and objectives The objectives of this study were to identify discrepancies on admission and at discharge and to detect the completeness of medication information in the discharge documents; and to assess the potential clinical impact of discrepancies. Material and methods A 4 week prospective interventional study was carried out in a 29 bed orthopaedic surgery ward of a regional hospital. On admission, the pharmacist compared his best possible medication history to previous medication histories and to prescriptions to identify discrepancies. They were classified by type, ATC classes and level of risk for the patient. Risk was evaluated by one physician and one clinical pharmacist assessing potential clinical impact and likelihood of occurrence. At discharge, completeness of medication related information in discharge letters and prescriptions was analysed. Discrepancies between inpatient treatment and discharge prescriptions were reported and their clinical impact was evaluated. Results 94 patients were included. On admission, 331 discrepancies with the previously recorded medication history were observed in 81 patients (92%). Regarding prescriptions, there were 97 unintentional discrepancies that impacted 41 patients (43.6%). Among these, 38 discrepancies (39.2%) were classified as high or extreme risk and involved psycholeptics, antidiabetic drugs and antithrombotic agents. Omission was the most common discrepancy. At discharge, 36 patients (40.4%) had at least a high or extreme risk discrepancy. Patients had a risk of treatment duplication. Antithrombotic agents were a major class in which patients were at extreme risk. Only 60% of drugs prescribed were found in the discharge letters. Conclusion and relevance Discrepancies and incomplete medication information are real issues at TOC. To improve patient care, the hospital pharmacist is a suitable and valuable healthcare professional. References and/or acknowledgements Conflict of interest No conflict of interest