Background: An accurate medication list at hospital admission is essential for the evaluation and further treatment\r\nof patients. The objective of this study was to describe the frequency, type and predictors of errors in medication\r\nhistory, and to evaluate the extent to which standard care corrects these errors.\r\nMethods: A descriptive study was carried out in two medical wards in a Swedish hospital using Lund Integrated\r\nMedicines Management (LIMM)-based medication reconciliation. A clinical pharmacist identified each patient�s\r\nmost accurate pre-admission medication list by conducting a medication reconciliation process shortly after\r\nadmission. This list was then compared with the patient�s medication list in the hospital medical records. Addition\r\nor withdrawal of a drug or changes to the dose or dosage form in the hospital medication list were considered\r\nmedication discrepancies. Medication discrepancies for which no clinical reason could be identified (unintentional\r\nchanges) were considered medication history errors.\r\nResults: The final study population comprised 670 of 818 eligible patients. At least one medication history error\r\nwas identified by pharmacists conducting medication reconciliations for 313 of these patients (47%; 95% CI 43-\r\n51%). The most common medication error was an omitted drug, followed by a wrong dose. Multivariate logistic\r\nregression analysis showed that a higher number of drugs at admission (odds ratio [OR] per 1 drug increase =\r\n1.10; 95% CI 1.06-1.14; p < 0.0001) and the patient living in their own home without any care services (OR = 1.58;\r\n95% CI 1.02-2.45; p = 0.042) were predictors for medication history errors at admission. The results further indicated\r\nthat standard care by non-pharmacist ward staff had partly corrected the errors in affected patients by four days\r\nafter admission, but a considerable proportion of the errors made in the initial medication history at admission\r\nremained undetected by standard care (OR for medication errors detected by pharmacists� medication\r\nreconciliation carried out on days 4-11 compared to days 0-1 = 0.52; 95% CI 0.30-0.91; p=0.021).\r\nConclusions: Clinical pharmacists conducting LIMM-based medication reconciliations have a high potential for\r\ncorrecting errors in medication history for all patients. In an older Swedish population, those prescribed many\r\ndrugs seem to benefit most from admission medication reconciliation.
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