Drug-related problems (DRPs) are defined as an ‘event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes’
. These problems are the cause of about 11% of the iatrogenic problems and could be avoided.
In France, the national survey of all serious adverse events associated with care (ENEIS) showed that 1.3% of hospitalizations (between 100,000 and 120,000 a year) are due to a serious drug-related iatrogenic event and are therefore avoidable
. Furthermore, more than half occur after a new prescription at admission or during discharge. In fact, the French health authority, through an accreditation procedure, requires hospitals to ensure treatment continuity from admission to discharge
An estimated 7 to 30% of patients present a DRP at hospital admission
. A reconciliation of medications supported by efficient communication between the hospital staff and community pharmacists (CPs), in addition to a standard patient interview and a general practitioner’s examination of prescriptions, was found to be effective in identifying medication discrepancies for inpatients
[5, 6]. Approximately 25 to 87% of patients experience DRPs after hospital discharge
[7–14]. Drug reconciliation before discharge was also found to be effective and could decrease DRPs by 50% when performed by a medical and/or pharmaceutical team; pharmaceutical teams were more effective in this process than medical or nursing teams
Medication reconciliation is defined as the formal process of checking the complete, accurate list of a patient’s previous medication and comparing it with the prescriptions after a transition of care (on admission, after transfer to another medical unit, and at discharge)
. The process has been recommended since 2005 by the Joint Commission on Accreditation to prevent errors. Countries such as Germany, the Netherlands, and France are involved in the World Health Organization (WHO) High 5’s procedure and particularly in medication reconciliation at admission
[20, 21]. Discrepancies between hospital treatment and home medication must be discussed with the prescriber and modifications made if necessary
. In fact, non-intentional discrepancies (NIDs) or intentional discrepancies (IDs) may be observed. An ID is a voluntary change in the patient’s medication (unnecessary drugs, route or dose change, or conformation to the hospital formulary). NIDs (wrong route or dose, missing treatment, or added drug) are considered medication errors. Among NIDs, 40 to 59% are potential causes of adverse events and 33% actually lead to adverse events
Several experiments have been conducted in North America or Europe to increase the quality of information at discharge, considering that well-informed patients and/or caregivers can manage the drug treatment on their own. However, few studies have focused on the role of the CP at discharge, both in the reconciliation process and/or the information needed to reduce DRPs (such as the medical discharge letter)
The primary objective of this study is to investigate a hospital pharmacist (HP) performing a reconciliation of medications with the patient at discharge, followed by communication between the HP and the CP, and their impact on the incidence of DRPs in patients during the seven days after discharge. The potential harmfulness of DRPs will be appraised by an expert committee. Secondary objectives are patient satisfaction and subgroup analyses.