Medication Discrepancies Identified at Time of Hospital Discharge in a Geriatric Population

Abstract

Background It has been reported that 14.1% of geriatric patients experience ≥1 medication discrepancies after hospitalization. Objective The goal of this study was to identify and characterize discharge medication list discrepancies among geriatric patients and to describe characteristics associated with discrepancies. Methods An institutional review board–approved retrospective review was conducted of patients aged ≥65 years discharged from hospitalist and internal medicine services at a large tertiary care hospital from August 2008 to December 2009. A random cohort of 200 patients was selected and categorized by age, gender, attending medical service, and the absence or presence of a pharmacist on the service. Medication lists were obtained from physician discharge summaries, discharge orders, and nursing discharge lists. Results A total of 1923 medication discrepancies were identified, consisting of 402 related to the absence or presence of a medication, 298 related to the dosage administered at one time, 223 related to the number of daily doses, and 1000 related to the route of administration. Physician discharge summaries contained the most medication discrepancies. There was no relationship between patient age and the number of medication discrepancies ( r 2 = 0.006; P = 0.279), whereas there was a linear relationship between the number of medications and the number of discrepancies ( r 2 = 0.249; P < 0.001). The internal medicine team with a pharmacist had a lower average number of discrepancies per patient compared with other medicine services that did not have a pharmacist present. Conclusions Medication discrepancies at the time of hospital discharge are a common occurrence for geriatric patients. Physician summaries might be the least reliable source of discharge medication lists. The number of discrepancies appears to not be associated with patient age, but rather with the number of medications at discharge. Discrepancies among medication lists are common, and the presence of a pharmacist may reduce the number that occur.