PS-041 Optimisation of medication reconciliation at patient admission to hospital: what about patient selection?

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Medication reconciliation at patient admission is performed for all patients hospitalised in the internal medicine unit at a teaching hospital in this study. Optimising pharmaceutical activities is a key issue.


The aim of this study was to assess the adequacy of pharmaceutical analysis after medication reconciliation at patient admission according to iatrogenic risks factors (IRF).

Material and methods

Pharmaceutical interventions (PI) were carried out by the pharmacist for each potentially inappropriate prescription. The following IRF were researched in hospitalised patients: severe renal impairment, cirrhosis, pregnancy, age ≥75 years, polypharmacy (≥ 5 drugs), not scheduled hospitalisation (through emergency or direct admission), immunosuppressive therapies, oral chemotherapy or other high risk medications.


151 inpatients were included in the study between November 2015 and May 2016. We achieved an average of 0.55, 0.32, 0.53, 0.78, 1.25 and 2.4 PI for patients with, respectively, 0, 1, 2, 3, 4 and 5 IRF. We identified 3 IRF that were more often associated with PI: severe renal impairment, age ≥75 years and polypharmacy with, respectively, 64%, 57% and 40% of patients having at least 1 PI. This study showed that if we have selected patients with at least 1 of these 3 risk factors (who represent 64% of admitted patients to the internal medicine unit), we would reconciled 90% of patients with at least 1 PI.


Pharmacists are more likely to suggest medicines optimisation to the elderly, to patients affected by polypharmacy or those suffering from severe renal dysfunction. Reducing our activities by 36%, 90% of patients who need at least 1 PI still benefit from pharmaceutical analysis. The clinical impact of the 10% of unrealised PI should be considered and compared with the benefits of the extra time setting up new activities, such as output information or therapeutic education of patients.

References and/or acknowledgements

Acknowledgements to the internal medicine unit.

References and/or acknowledgements

No conflict of interest

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