Role of a clinical pharmacist in cardiology units: Let's take the example of medication reconciliation (MR)!

Abstract

MR reduces medication errors by collecting an accurate history of medication of hospitalised patients. The exhaustive medication history is compared to the prescribed treatment. Discrepancies are discussed and resolved with prescribers. To describe unintentional medication discrepancies (UMD) and make a focus on cardiovascular drugs (CV-drugs). Data from MR realised in heart failure and rhythmology units during 2019 were extracted: treatment history, UMD types (unjustified drug addition or omission, difference in dose or rhythm of administration); discrepancies status (resolved or not) and drugs concerned by UMD. CV-drugs are represented by diuretics, antihypertensive drugs, β-blockers, antiarrythmics, but also anticoagulant/antiplatelet and lipid-lowering drugs. Five hundred and forty-three MR were realised and 239 (44%) show at least 1 UMD with a total of 656 highlighted UMD. Table 1 shows the UMD types’ repartition. Omission is the most common UMD (422, 64.3%) and often concerns CV-drugs ( n = 78), psychotropics ( n = 44), eye drops ( n = 43) and inhaled medications ( n = 39). Two hundred and fifty-three UMD with CV-drugs were recorded: 78 omissions (30.8%), 56 wrong dosages (22.1%), 23 differences in the rhythm of administration, 10 errors of medication and 7 unjustified drugs. Most of CV-drugs involved in omissions are lipid-lowering drugs ( n = 16) and RAAS blockers ( n = 15). Most of CV-drugs involved in dosage discrepancies are anticoagulants ( n = 17). Among the 239 MR, 221 were totally or partly resolved and 18 left unresolved. MR is an important process to reduce medication errors, minimizing omissions and dosage errors. As in previous studies, discrepancies frequently involve CV-drugs facing the medical historing of our patients but drugs of other specialties are concerned too. UMD left unresolved could have a clinical impact and increase the average length of stay. Physicians and pharmacists have to work side by side to secure points of transition in patients’ life. MR is a proven process for this issue.