Background: Inadequate information flow in the transition from hospital to home poses a challenge to medication safety, especially for patients with multiple long-term conditions (MLTCs).
Purpose: To investigate the frequency, categories, underlying reasons, and potential clinical relevance of medication discrepancies (MDs) by comparing medication lists in hospital discharge summaries with actual medication use after discharge in patients with MLTCs.
Methods: Home-dwelling adult patients with MLTCs, using minimum four medications were included near the time of their planned discharge, from one internal medicine and two geriatric wards in Oslo, to this cross-sectional observational study. Medication reconciliation was performed 1-2 weeks post-discharge. Discrepancies between the medication list in the discharge summary and the patient's medication use were classified into six categories. A panel assessed the potential clinical relevance of the MDs in a short-term and long-term perspective.
Results: 150 patients, median age 75 years (range 22-94), were included. 132 (88 %) had at least one MD, with a median of 3 per patient (range 0-10). The most common MDs involved medications in use although not listed in the discharge summary. Apparent lack of or insufficient medication reconciliation during the hospital stay was the most frequent reason for MDs. Of the MDs, 5.5 % and 28 % were assessed to be of potential clinical relevance in the short-term and long-term perspective, respectively.
Conclusion: Almost all patients had MDs following hospital discharge. The potential clinical relevance increases over time if MDs are not corrected. Our findings highlight the need for more effective interventions to ensure medication safety in care transitions for this vulnerable population.
Keywords: Hospital to home transition; Medication reconciliation; Medication therapy management; Multiple chronic conditions; Self-management.
Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.