{
  "abstract": "Background and Importance Elderly patients frequently present multimorbidity and polypharmacy, which increases the risk of medication errors and adverse drug events. Care transitions, such as hospital admission and discharge, are especially critical points for the occurrence of discrepancies. Medication reconciliation, when systematically implemented with the involvement of a clinical pharmacist, allows early detection and resolution of such discrepancies, ensuring therapeutic continuity and improving patient safety.Aim and Objectives To describe the types of discrepancies and their frequency, as well as the acceptance of pharmacist interventions.Material and Methods Retrospective study in a tertiary hospital from 1 January to 1 September 2025, including patients aged ≥75 years with ≥8 chronic treatments hospitalised in the orthopedic and trauma surgery Service. Medication reconciliation compared chronic therapy with hospital prescriptions at admission and discharge. Discrepancies were analysed and classified as omission, unjustified initiation, wrong dose/frequency/route, duplication, incomplete prescription or interaction. Physician acceptance of pharmacist interventions was recorded. A statistical analysis of results was performed, expressing continuous variables as mean ± standard deviation.Results A total of 188 patients were included; 71.3% women. Age was 83.0 ± 8.4 years, with 10,8 ± 3.4 chronic treatments.At admission, 208 discrepancies were identified in 117 patients, with physician acceptance of 72.6%. The most frequent were unjustified differences in dose, frequency or route (39.9%), omission of treatment (33.7%) and unjustified initiation (16.3%). Other discrepancies included interactions (4.8%), duplications (2.9%), unjustified substitutions (1.9%) and incomplete prescriptions (0.5%).At discharge, 111 discrepancies were detected in 73 patients. The distribution by type showed that most were incomplete prescriptions (61.3%), followed by unjustified differences in dose, frequency or route (28.8%), unjustified initiation (9.0%) and duplications (0.9%). Physician acceptance was 96.4%.Conclusion and Relevance Medication reconciliation detected numerous discrepancies at admission and discharge in elderly polymedicated patients, most of which required clarification. The high level of physician acceptance, particularly at discharge, reflects the clinical relevance of pharmacist interventions. These results highlight the importance of a multidisciplinary approach, including collaboration with the Geriatric and Orthopaedic and Trauma Surgery Services, to improve medication safety and optimise pharmacotherapy in this vulnerable population.Conflict of Interest No conflict of interest",
  "authors": [
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "S Maganto Garrido"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "S Fernández Lastras"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "M Montero Lázaro"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "A Martín Roldán"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "M Gómez Díaz"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "M Llorente Gómez"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "Á Bernabé Gonzalo"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "A Guerreiro Caamaño"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "Á Leon García"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "V Prol Da Costa"
    },
    {
      "affiliations": [
        "Hospital Clínico Universitario De Valladolid, Pharmacy Department, Valladolid, Spain"
      ],
      "name": "MT Sánchez Sánchez"
    }
  ],
  "title": "5PSQ-075 Impact of medication reconciliation at hospital admission and discharge in elderly polymedicated patients",
  "uid": "437ac47c-94a4-57b4-a14f-be6fa11bf992"
}