Drug therapy safety at the transition from hospital to community medicine

Abstract

We evaluated the qualitative and quantitative changes of medications during the stay on ageriatric-psychiatric ward where the medication was optimized by aclinical pharmacist, and after discharge. The goal of the study was to analyze the continuity of the medication at the transfer from hospital to ambulatory care. We interviewed 41patients on the phone about their drug regimen 4 and 12weeks after discharge. Medications were compared to their discharge medication. The number of medications from the PRISCUS list of inappropriate medications for the elderly as well as the number of drug interactions was documented. The drug interaction database MediQ was used to identify and classify the drug-drug interactions. During the hospitalization of the patients, 101 interventions of the clinical pharmacist were recommended and accepted. In cooperation with the physicians, the number of drug interactions decreased by 44% and the number of PRISCUS list medications by 42%. Only 4weeks after discharge, 54drugs for 27patients (66%) had already been changed. During the following 8weeks, another 44medications were changed in 14patients (35%). The total number of drugs after discharge did not change. The number of moderate drug interactions (p= 0.17) of medications from the PRISCUS list increased (p= 0.77), but not significantly. While the interventions of aclinical pharmacist can lead to areduction in drug interactions and inappropriate medication for the elderly during the hospitalization, the medication was changed after discharge in numerous cases. In adetailed analysis it was found that some of the changes increased the number of drug interactions as well as the number of potentially inappropriate medications for the elderly. Adrug interaction check after discharge could prevent drug interactions and medication errors. Also the nationwide medication plan can help to prevent medication errors by the prescribing physician as well as by the patient.