Actual Medication Use Research Articles

Longitudinal medication reconciliation at hospital admission, discharge and post-discharge.

Medication reconciliation (MR) is a widely recognised method to promote patient safety. However, its implementation is generally limited to an interaction at a single transition point. To examine the rates and types of changes implemented in patient's medication regimens when MR is performed longitudinally at hospital admission, discharge and post-discharge, and to assess the clinical impact. A prospective multicentre cohort study was conducted in two hospitals. Patients received MR at admission, discharge and within five days post-discharge at home. Data was collected on rates and types of changes implemented in their medication regimens, due to MR, at all three transition points. These changes entailed corrections of unintentional discrepancies, e.g., between patients' actual medication use and physician prescriptions, and optimisations of pharmacotherapy, e.g., adding laxatives when opioids are prescribed. Using a validated instrument, the clinical impact of all medication changes were scored. Data were analysed using descriptive statistics. In total, 197 patients with a median age of 73 years were included. In 86.3% of patients at least one change was implemented in the medication regimen due to longitudinal MR. At admission, discharge and post-discharge, changes in medication regimens were necessary in 66.5%, 62.9% and 52.8% of patients, respectively. At admission and post-discharge, mainly unintentional discrepancies were corrected, and at discharge mainly optimisations were implemented. Implemented medication changes, due to longitudinal MR, prevented potential harm in 161 patients (81.7%). Potentially serious medication errors were most often prevented at hospital discharge, and predominantly involved optimising antithrombotic agents. Changes in medication regimens were implemented in 86.3% of patients due to longitudinal MR at admission, discharge and post-discharge. The rates and types of medication changes vary over time. Hospital discharge is an important moment for optimising pharmacotherapy.

Medication safety risks to be managed in national implementation of automatic substitution of biological medicines: a qualitative study

ObjectivesTo explore relevant Finnish stakeholders’ perceptions on the automatic substitution of biological medicines with particular focus on medication safety and issues that need to be considered to create an appropriate...

Medication errors in primary health care records; a cross-sectional study in Southern Sweden

BackgroundDrug-related problems due to medication errors are common and have the potential to cause harm. This study, which was conducted in Swedish primary health care, aimed to assess how well the medication lists in the medical records tally with the medications used by patients and to explore what type of medication errors are present.MethodsWe reviewed the electronic medical records (EMRs) at ten primary health care centers in Skåne county, Sweden. The medication lists in the EMRs were compared with the results of medication reconciliations, which were performed telephonically in a structured manner by a physician, two weeks after a follow-up visit to a general practitioner. Of 76 patients aged ≥18 years, who on a certain day in 2016 were visiting one of the included primary health care centers, a total of 56 were included. Descriptive statistics were used. The chi2-test and the Mann Whitney U-test were used for comparisons. The main outcome measure was the proportion of correctly updated medication lists.ResultsFollowing a recent visit to the general practitioner, a total of 16% of the medication lists in the medical records were consistent with the patients’ actual medication use. The mean number of medication errors in the medical records was 3.8 (SD 3.8). Incorrect dose was the most common error, followed by additional drugs without indication/documentation. The most common medication group among all errors was analgesics and among dose errors the most common medication group was cardiovascular drugs.ConclusionA total of 84% of the medication lists used by the general practitioners in the assessment and follow-up of the patients were not updated; this implies a great safety risk since medication errors are potentially harmful. Ensuring medication reconciliations in daily clinical practice is important for patient safety.

Validity of a nationwide medication record system in the Netherlands.

Background In the Netherlands, a nationwide Medication Record System based on pharmacy dispensing data is used to obtain information about patients' actual medication use. However, it is not clear to what extent the information of the Nationwide Medication Record System corresponds to the medication information obtained with the Best Possible Medication History. Objective To examine the validity of medication dispensing records collected from the Nationwide Medication Record System by comparing them to the Best Possible Medication History. Method An observational study was performed. Patients from several hospital departments were included at admission. To obtain the Best Possible Medication History, pharmacy technicians performed medication reconciliation at admission, using dispensing records from the Nationwide Medication Record System and information from the patient himself. Primary outcome is percentage of patients with no discrepancies between the Nationwide Medication Record System and the Best Possible Medication History. Descriptive analysis was used. Results Eighty-two patients were approached and 66 (80%) were included, with in total 478 medicines in the Best Possible Medication History. Seventeen percent of the patients had no discrepancies and 33% (n = 156) of the medication records contained a discrepancy between the Nationwide Medication Record System and the Best Possible Medication History. Most common type of discrepancy was omission (44%). Conclusion Even with a Nationwide Medication Record System medication reconciliation with the patient remains essential to obtain complete information about patient's actual medication use.

Understanding of antidiabetic medication is associated with blood glucose in patients with type2 diabetes: At baseline date of the KAMOGAWA-DM cohort study.

Aims/IntroductionMedication adherence, which is decreased by a poor understanding of medications, has a close association with blood glucose level in patients with type 2 diabetes. However, a relationship between the understanding of antidiabetic medication and blood glucose level in patients with type 2 diabetes is unclear. Here, we aimed to investigate the relationship between the understanding of antidiabetic medication and blood glucose level in patients with type 2 diabetes.Materials and MethodsLifestyle factors were evaluated by a questionnaire method, in the present cross‐sectional study. Poor understanding of antidiabetic medication (PUAD) was defined as a discrepancy between the answer and the actual use of oral antidiabetic medication on the questionnaire. Poor blood glucose level was defined as hemoglobin A1c ≥8%. To investigate the impact of PUAD on poor blood glucose level, propensity‐score matching analysis was used to remove the bias of confounding variables, including sex, age, log (duration of diabetes +1), body mass index, number of oral antidiabetic medications, smoking status, alcohol drinking, exercise, nephropathy, neuropathy, oral antidiabetic medications and insulin.ResultsAmong 479 patients, 40 patients (8.4%) were categorized into the PUAD group. The hemoglobin A1c of patients with PUAD was higher than that of patients without (7.5 [1.3] vs 7.2 [0.9]%, P = 0.041). In the propensity‐matched 74 patients, PUAD was associated with poor blood glucose level (odds ratio 5.45, 95% confidence interval 1.54–25.8, P = 0.007) by logistic regression analysis.ConclusionA poor understanding of antidiabetic medication is associated with poor blood glucose level in patients with type 2 diabetes.

Considerations of prescribers and pharmacists for the use of non-selective β-blockers in asthma and COPD patients: An explorative study.

Rationale, aims, and objectivesDespite recommendations in prevailing guidelines to avoid the use of non‐selective (NS) β‐blockers in patients with asthma or COPD, on average, 10 patients per community pharmacy receive NS β‐blockers monthly. The aim of our study was to identify the reasons of prescribers and pharmacists to treat asthma and COPD patients with NS β‐blockers.MethodsFifty‐three community pharmacists in the Netherlands selected patients with actual concurrent use of inhalation medication and NS β‐blockers. For at least 5 patients, each pharmacist screened all medication surveillance signals and actions taken at first dispensing. Each pharmacist selected 3 different initial prescribers for a short interview to explore their awareness of the co‐morbidity and reasons to apply NS β‐blockers.ResultsPharmacists identified 827 asthma/COPD patients with actual use of NS β‐blockers. From these, 153 NS β‐blocker prescribers were selected and interviewed (64 general practitioners, 45 ophthalmologists, 24 cardiologists, and 20 other prescribers). One hundred seven prescribers were aware of the drug‐disease interaction of the asthma or COPD co‐morbidity when initiating the NS β‐blocker, and 46 were not. From these, 40 prescribers did not consider the contraindication to be relevant.For 299 patients, medication surveillance signals and actions at first dispensing were retrieved. Patients used predominantly ocular timolol (39.8%), and the oral preparations propranolol (30.8%) and carvedilol (15.1%). In 154 cases, the pharmacy system generated a warning alert.ConclusionsA substantial number of prescribers was unaware of the co‐morbidity or did not regard NS β‐blockers contraindicated, despite prevailing clinical guidelines. Improvement programs should target prescribers' awareness and knowledge of NS β‐blockers in patients with asthma or COPD.

Mind the Gap: Mismatches Between Clinicians and Patients in Heart Failure Medication Management.

Previous studies on the 'treatment gap' in patients with heart failure (HF) have focused either on prescribing or patients' adherence to prescribed treatment. This study sought to determine whether or not recent initiatives to close the gap have also minimised any mismatches between physicians' expectation of their patients' medications, medications in the patients' possession and their actual medication use. A cross-sectional observational survey was conducted from December 2015 to June 2016 in The Alfred Hospital HF clinic in Melbourne, Australia. Patients were invited to participate if they had chronic HF (NYHA class II to IV), were aged ≥ 60years, had no history of HF related hospitalisation within the past 6months and were prescribed at least two HF medications. Of 123 eligible patients, 102 were recruited into the study. Beta-blockers, mineralocorticoid receptor antagonists, loop diuretics and statins were associated with the highest rates of mismatches of drugs and doses, ranging from 10 to 17%. Discrepancy of total daily doses was the most common type of mismatch. Overall, only 23.5% of the patients were taking the right drugs at the right doses as expected by their cardiologists/HF specialists. Despite improved prescribers' adherence to guideline-directed medical therapy, there remain considerable mismatches between prescribers' expectation of patients' HF medications, medications in patients' possession and their actual medication use. Initiatives to improve this situation are urgently needed.

Developing and testing an electronic medication administration monitoring device for community dwelling seniors: a feasibility study

BackgroundMedication non-adherence, polypharmacy, and adverse drug events are major healthcare issues leading to significant morbidity, mortality, and healthcare expenditures. Currently, there are no methods to systematically track medication usage in community-dwelling seniors. The eDosette prototype was created to make medication use patterns visible via the Internet. This study aims to demonstrate feasibility, usability, and acceptability of the eDosette in community-dwelling seniors in primary care.MethodsA 2-week feasibility study involving a convenience sample of 10 patients from an academic family medicine teaching unit in Hamilton, Ontario, Canada, was conducted over a 6-month period between April and October 2015. The eDosette transmitted hourly electronic data via the Internet on each participant’s pattern of medication use; this data was converted into an individualized medication administration record (MAR). Based on the MARs from the 10 participants, the frequency of missed medication doses, the time of dose administration, and each participant’s adherence rate for their prescribed medications could be determined. A medication adherence survey and a patient usability and acceptability survey were administered to all the participants of the study.ResultsThe eDosette was able to record a participant’s medication use and transmit this data electronically via the Internet with sufficient quality to create participant-specific MARs. A total of 418 doses were captured by the eDosette throughout the study; only 5% (n = 22 doses) were missing information or had poor image quality. Analysis of the MARs revealed that 19% (n = 79 doses) were taken outside a 2-h window of the average dose administration time, and two doses were completely missed by all participants during this feasibility study. Participant feedback found the eDosette easy and acceptable to use. Participant feedback also identified hardware and software issues that require attention prior to a larger study.ConclusionsThe eDosette is a feasible and novel technology that can be successfully installed into the homes of community-dwelling seniors to help in monitoring actual medication use patterns. This study provided details for further device development and evidence to support the need for a larger pilot study on the eDosette’s impact on medication adherence.

Medication Discrepancies at Outpatient Departments for Mood and Anxiety Disorders in the Netherlands

To identify discrepancies between actual drug use by outpatients with mood and anxiety disorders and medication overviews from health care providers as well as to investigate the clinical relevance of those discrepancies. A cross-sectional study in adults visiting 1 of 4 participating outpatient departments for mood and anxiety disorders was conducted between March and November 2014. DSM-5 criteria were used to assign the psychiatric diagnosis. The primary outcome was the number of discrepancies between the actual medication use, as determined by medication reconciliation with the patient, and the medication overview from the outpatient department, general practitioner, and community pharmacy. Our secondary outcome was the clinical relevance of discrepancies, as assessed by an expert panel that reviewed all discrepancies for their potential to cause patient harm. Of 367 patients included, 94.8% had at least 1 discrepancy in the medication overview from the outpatient department. A mean of 3.9 discrepancies existed per patient. Most discrepancies (74.5%) related to omitted drugs (drugs taken regularly by patients but absent from the medication overview). Of all discrepancies at the outpatient departments, 22.7% had the potential to cause moderate to severe discomfort or clinical deterioration, affecting 49.3% of the patients. Both total number and number of clinically relevant discrepancies were lower in medication overviews from general practitioners and pharmacies. Patients from outpatient departments for mood and anxiety disorders may be at substantial risk for medication discrepancies that are often clinically relevant. Medication reconciliation at mental health care outpatient departments is in need of improvement.

Exploring discharge prescribing errors and their propagation post-discharge: an observational study.

Background Discharge prescribing error is common. Little is known about whether it persists post-discharge. Objective To explore the relationship between discharge prescribing error and post-discharge medication error. Setting This was a prospective observational study (March-May 2013) at an adult academic hospital in Ireland. Method Patients using three or more chronic medications pre-admission, with a clinical pharmacist documented gold-standard pre-admission medication list, having a chronic medication stopped or started in hospital and discharged to home were included. Within 10-14days after discharge a gold standard discharge medication was prepared and compared to the discharge prescription to identify differences. Patients were telephoned to identify actual medication use. Community pharmacists, general practitioners and hospital prescribers were contacted to corroborate actual and intended medication use. Post-discharge medication errors were identified and the relationship to discharge prescribing error was explored. Main outcome measured Incidence, type, and potential severity of post-discharge medication error, and the relationship to discharge prescribing. Results Some 36 (43%) of 83 patients experienced post-discharge medication error(s), for whom the majority (n=31, 86%) were at risk of moderate harm. Most (58 of 66) errors were discharge prescribing errors that persisted post-discharge. Unintentional prescription of an intentionally stopped medication; error in the dose, frequency or formulation and unintentional omission of active medication are the error types most likely to persist after discharge. Conclusion There is a need to implement discharge medication reconciliation to support medication optimisation post-hospitalisation.

Information on actual medication use and drug-related problems in older patients: questionnaire or interview?

Background Information on medication use and drug-related problems is important in the preparation of clinical medication reviews. Critical information can only be provided by patients themselves, but interviewing patients is time-consuming. Alternatively, patient information could be obtained with a questionnaire. Objective In this study the agreement between patient information on medication use and drug-related problems in older patients obtained with a questionnaire was compared with information obtained during an interview. Setting General practice in The Netherlands. Method A questionnaire was developed to obtain information on actual medication use and drug-related problems. Two patient groups ≥65 years were selected based on general practitioner electronic medical records in nine practices; I. polypharmacy and II. ≥1 predefined general geriatric problems. Eligible patients were asked to complete the questionnaire and were interviewed afterwards. Main outcome measure Agreement on information on medication use and drug-related problems collected with the questionnaire and interview was calculated. Results Ninety-seven patients participated. Of all medications used, 87.6 % (95 % CI 84.7–90.5) was reported identically in the questionnaire and interview. Agreement for the complete medication list was found for 45.4 % (95 % CI 35.8–55.3) of the patients. On drug-related problem level, agreement between questionnaire and interview was 75 %. Agreement tended to be lower in vulnerable patients characterized by ≥4 chronic diseases, ≥10 medications used and low health literacy. Conclusion Information from a questionnaire showed reasonable agreement compared with interviewing. The patients reported more medications and drug-related problems in the interview than the questionnaire. Taking the limitations into account, a questionnaire seems a suitable tool for medication reviews that may replace an interview for most patients.Electronic supplementary materialThe online version of this article (doi:10.1007/s11096-016-0258-9) contains supplementary material, which is available to authorized users.

What we have learned from a decade of ED crowding research.

What we have learned from a decade of ED crowding research.

Actual Use of Medications Prescribed During Pregnancy: A Cross-Sectional Study Using Data from a Population-Based Congenital Anomaly Registry

Introduction and AimData from prescription databases are increasingly being used to study associations between maternal medications used in pregnancy and congenital anomalies. We therefore investigated the extent to which prescriptions reflect the actual use of medication during pregnancy, and whether medicines used during pregnancy are taken according to the prescribed dosage and duration.MethodsWe performed a cross-sectional study in a population-based congenital anomaly register (EUROCAT Northern Netherlands). We included 202 women who had at least one prescription during their pregnancy and who gave birth between 2009 and 2011. Compliance with the prescribed medication was verified by telephone interview. We calculated the compliance rates for several medication groups by dividing the number of mothers who confirmed they had taken the medication by the total number to whom it had been prescribed. Compliance was positive if the mother confirmed she took the medication, even if she only took one of several prescriptions from the same medication group. For each prescription taken, we also determined whether her use conformed to the prescribed dosage and duration.ResultsDuring the first trimester, the compliance rates ranged from 0.84 (for chronic diseases) to 0.92 (for pregnancy-related symptoms). Most of the medications actually taken were used at the prescribed dosage or lower. More than half of the medications actually taken were used for the duration prescribed or shorter.ConclusionPrescription records are generally a relatively reliable source of data for research into associations between medication use in pregnancy and congenital anomalies compared with other data sources. Pharmacy records of medication use in pregnancy might represent an overestimation, which should be taken into account. However, our results show that, except for ‘corticosteroids, dermatological preparations’; ‘ear, eye, nose and throat preparations’; and ‘anxiolytics, hypnotics and sedatives’, this overestimation generally seems minimal.Electronic supplementary materialThe online version of this article (doi:10.1007/s40264-015-0302-z) contains supplementary material, which is available to authorized users.

Coping with menopausal symptoms: an internet survey of Belgian postmenopausal women

Objectives: An internet survey was performed to obtain current data on the actual use of medication, hormonal replacement and over the counter products to cope with menopausal symptoms, in Belgium. Opt-in Internet access panels of TalkToChange and GMI were evaluated as a potential new way to obtain data on insights of women on menopausal issues.

Adherence, exposure and patients' experiences with the use of erlotinib in non-small cell lung cancer.

PurposeErlotinib is an orally administered tyrosine kinase inhibitor used for treatment of non-small cell lung cancer. Understanding actual use of medication is essential for optimizing treatment conditions.MethodsIn this multicentre prospective observational study, patients starting erlotinib treatment were followed for 4 months. Adherence was assessed using a medication event monitoring system (MEMS). Area under the curve (AUC) was determined after 1, 2 and 4 months. Before start and at monthly intervals, patients filled out questionnaires about attitude towards medication and disease, quality of life, symptoms and use in daily practice.ResultsSixty-two patients (median age 63.5 years, 53 % male) were included of whom 15 were still on treatment after 4 months. MEMS data of 55 patients revealed a mean adherence of 96.8 ± 4.0 %. Over one-third of patients had an adherence rate <95 %. At 1 month, 21 % of patients did not always correctly take erlotinib without food. Associated risk factors were older age, suboptimal adherence, ocular symptoms and stomatitis (all p < 0.05). After 1 month of treatment, fatigue (91 %) and rash (86 %) were the most common symptoms reported. AUCss of erlotinib was higher in patients with rash and patients with moderate–severe anorexia (both p < 0.05).ConclusionThough adherence to erlotinib treatment is generally high, non-adherence might be an issue in a considerable number of patients. To support optimal erlotinib intake, clinicians need to take adequate measures to ameliorate symptoms and to address adherence and correct intake without food. Especially older patients and those who experience stomatitis may need extra attention.

Medication persistence and discontinuation of rivaroxaban versus warfarin among patients with non-valvular atrial fibrillation

Objectives:To compare real-world persistence and discontinuation among non-valvular atrial fibrillation (NVAF) patients on rivaroxaban and warfarin in the US.Research design and methods:A large nationally representative US claims database was used to conduct a retrospective cohort analysis of patients with NVAF treated with rivaroxaban or warfarin from 1 July 2010 through 31 March 2013. Index date was the date of the first prescription of rivaroxaban or warfarin. All patients were followed until the earliest of inpatient death, end of continuous enrollment, or end of study period. Rivaroxaban patients were matched 1:1 by propensity scores. Medication persistence was defined as absence of refill gap of ≥60 days. Discontinuation was defined as no additional refill for at least 90 days and until the end of follow-up. Cox proportional hazards models were estimated to examine the adjusted hazard ratios (aHRs) of rivaroxaban vs. warfarin on non-persistence and discontinuation.Results:A total of 32,886 NVAF patients on rivaroxaban or warfarin met the study inclusion criteria. Each of the 7259 rivaroxaban patients identified were matched 1:1 to warfarin patients. Patients on rivaroxaban had a significantly better rate of persistence (aHR: 0.63, 95% CI 0.59–0.68) and lower rate of discontinuation (aHR: 0.54, 95% CI 0.49–0.58) compared to warfarin recipients.Limitations:Claims data may have contained inaccuracies and miscoding. Confounding may remain even after propensity score matching and additional adjustments in model. Refill data may not fully reflect actual medication use. Longer follow-up may produce more precise estimates of persistence and discontinuation.Conclusion:This matched cohort analysis indicated that rivaroxaban was associated with significantly higher medication persistence and lower discontinuation rates compared to warfarin.

OP0036 Fewer Patients on Biologicals and Better Functional Ability Two Years after Induction Therapy with Combination DMARD Therapy versus Methotrexate Monotherapy

BackgroundFewer patients on biologicals and better functional ability two years after induction therapy with combination DMARD therapy versus methotrexate monotherapyObjectivesTo assess differences in frequency of biological therapy use in early...

Dutch women in midwife-led care at the onset of labour: which pain relief do they prefer and what do they use?

BackgroundPain experienced during labour is more extreme than many other types of physical pain. Many pregnant women are concerned about labour pain and about how they can deal with this pain effectively.The aim of this study was to examine the associations among low risk pregnant women’s characteristics and their preferred use and actual use of pain medication during labour.MethodsOur study is part of the DELIVER study: a dynamic prospective multi-centre cohort study. The data for this study were collected between September 2009 and March 2011, from women at 20 midwifery practices throughout the Netherlands. Inclusion criteria for women were: singleton pregnancies, in midwife–led care at the onset of labour and speaking Dutch, English, Turkish or Arabic. Our study sample consisted of 1511 women in primary care who completed both questionnaire two (from 34 weeks of pregnancy up to birth) and questionnaire three (around six week post partum). These questionnaires were presented either online or on paper.ResultsFifteen hundred and eleven women participated. Prenatally, 15.9% of women preferred some method of medicinal pain relief. During labour 15.2% of the total sample used medicinal pain relief and 25.3% of the women who indicated a preference to use medicinal pain relief during pregnancy, used pain medication. Non-Dutch ethnic background and planned hospital birth were associated with indicating a preference for medicinal pain relief during pregnancy. Primiparous and planned hospital birth were associated with actual use of the preferred method of medicinal pain relief during labour. Furthermore, we found that 85.5% of women who indicated a preference not to use pain medication prenatally, did not use any medication.ConclusionsOnly a small minority of women had a preference for intrapartum pain medication prenatally. Most women did not receive medicinal pain relief during labour, even if they had indicated a preference for it.Care providers should discuss the unpredictability of the labour process and the fact that actual use of pain medication often does not match with women’s preference prenatally.

Metrics of salbutamol use as predictors of future adverse outcomes in asthma

Beta-agonist overuse is associated with adverse outcomes in asthma, however, the relationships between different metrics of salbutamol use and future risk are uncertain. To investigate the relationship between metrics of salbutamol use and adverse outcome. In a 24-week randomized controlled trial of 303 asthma patients at risk of severe exacerbations which compared the efficacy and safety of combination budesonide/formoterol inhaler according to a single inhaler regimen (SMART) with a fixed-dose regimen with salbutamol as reliever ('Standard'), actual medication use was measured by electronic monitoring (Australian New Zealand Clinical Trials Registry Number ACTRN12610000515099). A nested cohort study explored the relationship between metrics of baseline salbutamol use over 2weeks and future severe asthma exacerbations, poor asthma control (ACQ-5≥1.5) or 'extreme' salbutamol overuse (>32 salbutamol actuations/24-h period). Higher mean daily salbutamol use (per two actuations/day) [Odds ratio (OR) (95% CI) 1.24 (1.06-1.46)], higher days of salbutamol use (per 2days in 2weeks) [OR 1.15 (1.00-1.31)] and higher maximal 24-h use (per two actuations/day) [OR 1.09 (1.02-1.16)] were associated with future severe exacerbations. Higher mean daily salbutamol use was associated with future poor asthma control [OR 1.13 (1.02-1.26)]. Higher mean daily salbutamol use [OR 2.73 (1.84-4.07)], number of days of use [OR 1.46 (1.24-1.71)], and maximal daily use [OR 1.57 (1.31-1.89)] were associated with an increased risk of future extreme salbutamol overuse. Electronically recorded frequency of current salbutamol use is a strong predictor of risk of future adverse outcomes in asthma, with average daily use performing the best. These findings provide new information for clinicians considering metrics of salbutamol as predictors of future adverse outcomes in asthma.

Use of a Structured Medication History to Establish Medication Use at Admission to an Old Age Psychiatric Clinic: A Prospective Observational Study

Medication reconciliation results in fewer adverse drug events. The first step in medication reconciliation is to carry out a structured interview about medication use. It is not known whether such an interview is useful in inpatient old age psychiatry. The object of this study was to determine at admission the number of discrepancies in medication use, comparing the structured history of medication use (SHIM) procedure with the usual procedure for taking the medication history. A prospective observational study was conducted. All consecutive patients aged 55 years and older admitted from January until April 2011 to the inpatient old age psychiatric clinic of a large psychiatric teaching hospital in The Hague, the Netherlands, were eligible for inclusion; 50 patients were included. In every patient, the usual procedure (medication history-taking at admission by the treating physician) was compared with the SHIM procedure administered by the researcher. The SHIM procedure consists of a structured interview with the patient about the actual use of medication, incorporating the information from the community pharmacy and the patient's medications brought to the interview. The main outcome was the number of discrepancies in recorded medication use between the SHIM and the usual procedure. In total, 100 discrepancies (median 2 per patient, range 0-8) in medication use were identified; 78 % (n = 39) of the patients had at least one discrepancy. Of the discrepancies, 69 % were drug omissions, and 31 % were drug additions or discrepancies in the frequency or dosage of medications. Eighty-two percent of all discrepancies were potentially clinically relevant. In 24 % of the patients, the discrepancies had clinical consequences. The number of discrepancies that were found suggests that the usual procedure for taking the medication history can be improved. The SHIM procedure enables a comprehensive and accurate overview of the medication used by older patients admitted to a psychiatric hospital, and contributes to the prevention of clinically relevant adverse drug events.