The effect of medication reconciliation in elderly patients at hospital discharge

Int J Clin Pharm. 2012 Feb;34(1):113-9. doi: 10.1007/s11096-011-9599-6. Epub 2011 Dec 30.


Objective: To assess the impact of medication reconciliation interventions on medication error rates when elderly patients are discharged from hospital to community care or nursing homes.

Setting: Elderly patients (>65 years) living in nursing homes or in their own homes with care provided by the community nursing system.

Method: All medical records containing information on drug treatment were collected from hospital departments, the community care service and GPs. We then identified if there were any changes in the transfer of information i.e. if the drugs were not the same as before the transfer. Two different persons independently evaluated all information about the patients' drugs to identify medication errors for three different time periods. During all three periods structured discharge information was used. In period 2, electronic medication lists were introduced and in period 3 we introduced specific routines and support by a clinical pharmacist to ensure prescription in the specific medication dispensing system (ApoDos). Asymptotic Linear by-Linear Association Test was used to compare number of medication errors in period 1, 2 and 3 respectively.

Main outcome measure: Number of medication errors per patient.

Results: A total of 123 patients were evaluated at discharge. For the 109 patients using the ApoDos system, there were significant differences in the number of medication errors between period 1 and 3 (P = 0.048), period 2 and 3 (P = 0.037 but not between period 1 and 2 (P = 0.41). The mean numbers of errors were 1.5, 1.1 and 0.5 for period 1, 2 and 3 respectively. The 14 patients not using the ApoDos system had on average 0.4 errors per patient. Among the 58 patients with medication errors, 34 were evaluated as having low clinical risk, 22 moderate, and 2 high clinical risk.

Conclusion: Medication errors are still common when elderly patients are transferred from hospital to community/primary care. The main risk factor seems to be the specific medication dispensing system (ApoDos) or rather the process on how to use it. When this system was supported by clinical pharmacists, the error rate dropped to the same level as for patients without ApoDos.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Female
  • Humans
  • Male
  • Medical Records / statistics & numerical data
  • Medication Errors / prevention & control*
  • Medication Errors / statistics & numerical data
  • Medication Reconciliation / methods*
  • Medication Systems, Hospital / organization & administration*
  • Patient Discharge*
  • Pharmacists / organization & administration
  • Pharmacy Service, Hospital / organization & administration
  • Risk Factors
  • Time Factors