{
  "abstract": "Background and Importance Medication reconciliation (MR) by hospital pharmacy staff aims to reduce patient safety risks during care transitions. Incorrect medication information transfer often results in medication discrepancies (MDs), associated with patient harm, preventable hospitalisations, and increased costs. Unlike previous studies focusing on single transitions, this study assesses medication transfer across multiple transitions: hospital admission, discharge, outpatient clinics, and primary care.Aim and Objectives This study primarily aimed to quantify the proportion of patients with ≥1 MD or unintentional MD (UMD) across care transitions. Secondary aims included assessing the time required for MR and associated costs.Material and Methods A prospective observational cohort study was conducted in two Dutch hospitals (July-September 2024). Adults (≥18 years) using ≥3 prescribed medications were included. At admission and discharge, medication lists reconciled by pharmacy technicians were compared with the Nationwide Medication Record System (NMRS). Medication lists from community pharmacies, and general practitioners (GP) were obtained and compared to the reconciled hospital medication list at admission and discharge. For outpatient clinics, physicians’ medication lists were compared with the NMRS. In hospitals, UMDs were verified with treating physicians; this was not feasible for primary care. Primary outcome was the percentage of patients with ≥1 UMD (admission, discharge, outpatient clinics) or ≥1 MD (community pharmacies, GP records). Secondary outcomes were MR time and costs. Descriptive statistics were used.Results A total of 144 patients were included (82 (57%) female; median age 65 years, IQR 55-75). At admission 65 patients were included, at discharge 66, and at outpatient clinics 66.At admission six (9%) patients had ≥1 UMD; at discharge, nine (14%); and at outpatient clinics, 29 (44%) compared to the NMRS.Compared to medication lists of community pharmacies, 47 (76%) patients at admission and 46 (78%) at discharge had ≥1 MD. Compared to medication lists of GPs, these were 43 (78%) and 52 (90%), respectively.Median MR time was 12 minutes at admission, 10 at discharge, and 1.4 at outpatient clinics, corresponding to costs of €6.00, €5.00, and €3.21 per patient.Conclusion and Relevance MDs are common, particularly where pharmacy technicians are not involved. The time and costs required highlight the need for improved medication information transfer.Conflict of Interest No conflict of interest",
  "authors": [
    {
      "affiliations": [
        "Maastricht University Medical Centre+, Clinical Pharmacy and Toxicology, Maastricht, The Netherlands",
        "Carim Cardiovascular Research Institute Maastricht- Maastricht University, Department of Clinical Pharmacy, Maastricht, The Netherlands"
      ],
      "name": "B Limmen"
    },
    {
      "affiliations": [
        "University of Groningen- University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands"
      ],
      "name": "J Van Broekhuizen"
    },
    {
      "affiliations": [
        "Erasmus University Medical Centre, Department of Hospital Pharmacy, Rotterdam, The Netherlands"
      ],
      "name": "A Abdulla"
    },
    {
      "affiliations": [
        "Antonius Hospital Sneek, Department of Clinical Pharmacy, Sneek, The Netherlands"
      ],
      "name": "M Duyvendak"
    },
    {
      "affiliations": [
        "Netherlands Institute for Health Services Research Nivel, Organisation and Quality of Care, Utrecht, The Netherlands"
      ],
      "name": "L Van Eikenhorst"
    },
    {
      "affiliations": [
        "Netherlands Institute for Health Services Research Nivel, Pharmaceutical Care, Utrecht, The Netherlands"
      ],
      "name": "K Hek"
    },
    {
      "affiliations": [
        "Maastricht University Medical Centre+, Department of Clinical Pharmacy and Toxicology, Maastricht, The Netherlands",
        "Nutrim- Institute of Nutrition and Translational Research In Metabolism- Maastricht University, Department of Clinical Pharmacy-, Maastricht, The Netherlands"
      ],
      "name": "J De Ruijter-Van Dalem"
    },
    {
      "affiliations": [
        "university of Groningen- University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology-, Groningen, The Netherlands"
      ],
      "name": "PMLAVan Den Bemt"
    },
    {
      "affiliations": [
        "Carim Cardiovascular Research Institute Maastricht- Maastricht University, Department of Clinical Pharmacy, Maastricht, The Netherlands",
        "Maastricht University Medical Centre+, Department of Clinical Pharmacy and Toxicology, Maastricht, The Netherlands"
      ],
      "name": "F Karapinar"
    }
  ],
  "title": "4CPS-094 Prevalence and impact of medication discrepancies across care transitions: a prospective observational cohort study in hospitals",
  "uid": "d1b624e3-4696-5a02-92ac-1225e5d92255"
}