WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT• Managing a patient's medication(s) at points around transfer of care is central to patient safety and high quality care.• Medication use at these points carries the potential for miscommunication and medication error.• Processes of reconciliation can help to reduce the prevalence of miscommunication and error, improve continuity of appropriate medication use and improve communication across different settings. However, such processes are resource intensive. WHAT THIS PAPER ADDS• Medication details documented at discharge from acute hospital care in Ireland frequently contain prescription writing errors or fail to communicate information regarding changes made during inpatient care (collectively referred to as nonreconciliations).This carries the potential to cause harm or unplanned re-admission.• The medication classes that are more likely to be omitted at admission or discharge were identified, as were those involved in failure to document changes made during inpatient care, for example stopping or withholding.• Patients experiencing chronic illness and using an increasing number of medications were identified as being at greatest risk of experiencing non-reconciliation, and it is recommended that processes of reconciliation should be prioritized for these patients.• Processes that require the same medication details to be written more than once increase the likelihood of non-reconciliation. AIMSMovement into or out of hospital is a vulnerable period for medication safety.Reconciling the medication a patient is using before admission with the medication prescribed on discharge, and documenting any changes (medication reconciliation) is recommended to improve safety.The aims of the study were to investigate the factors contributing to medication reconciliation on discharge, and identify the prevalence of non-reconciliation. METHODSThe study was a cross-sectional, observational survey using consecutive discharges from purposively selected services in two acute public hospitals in Ireland. Medication reconciliation, potential for harm and unplanned re-admission were investigated. RESULTSMedication non-reconciliation was identified in 50% of 1245 inpatient episodes, involving 16% of 9569 medications.The majority of non-reconciled episodes had potential to result in moderate (63%) or severe (2%) harm. Handwritten rather than computerized discharges (adjusted odds ratio (adjusted OR) 1.60, 95% CI 1.11, 2.99), increasing number of medications (adjusted OR 1.26, 95% CI 1.21, 1.31) or chronic illness (adjusted OR 2.08, 95% CI 1.33, 3.24) were associated with non-reconciliation. Omission of endocrine, central nervous system and nutrition and blood drugs was more likely on discharge, whilst omission on admission and throughout inpatient care, without documentation, was more likely for obstetric, gynaecology and urinary tract (OGU) or respiratory drugs. Documentation in the discharge communication that medication was intentionally stopped during inpatient care was less likely for c...

BackgroundWe investigated the benefits of the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT) service versus standard ward-based clinical pharmacy in adult inpatients receiving acute medical care, particularly on prevalence of medication error and quality of prescribing.MethodsUncontrolled before-after study, undertaken in consecutive adult medical inpatients admitted and discharged alive, using at least three medications. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT intervention involved clinical pharmacists being team-based, leading admission and discharge medication reconciliation and undertaking prescription review. Primary outcome measures were prevalence per patient of medication error and potentially severe error. Secondary measures included quality of prescribing using the Medication Appropriateness Index (MAI) in patients aged ≥65 years.FindingsSome 233 patients (112 PACT, 121 standard) were included. PACT decreased the prevalence of any medication error at discharge (adjusted OR 0.07 (95% CI 0.03 to 0.15)); number needed to treat (NNT) 3 (95% CI 2 to 3) and no PACT patient experienced a potentially severe error (NNT 20, 95% CI 10 to 142). In patients aged ≥65 years (n=108), PACT improved the MAI score from preadmission to discharge (Mann–Whitney U p<0.05; PACT median −1, IQR −3.75 to 0; standard care median +1, IQR −1 to +6).ConclusionsPACT, a collaborative model of pharmaceutical care involving medication reconciliation and review, delivered by clinical pharmacists and physicians, at admission, during inpatient care and at discharge was protective against potentially severe medication errors in acute medical patients and improved the quality of prescribing in older patients.

Standard teicoplanin dosing regimens should be used with caution in patients with haematological malignancy. Bodyweight, CLCR and serum albumin concentration are important considerations for appropriate dosing.

19Objectives: To describe the population pharmacokinetics of teicoplanin in adult haematological 20 malignancy patients receiving higher than standard doses and to perform Monte Carlo simulations 21 to determine dosing regimens associated with optimal teicoplanin concentrations. 22Methods: This was a hospital-based clinical trial (EudraCT 2013-004535-72). Nine blood samples 23 were collected on Day 3, plus single trough samples on Days 7 and 10, and 24 and 48 h post last 24 dose. Teicoplanin minimum inhibitory concentrations were determined for Gram-positive isolates 25 from study patients. Population pharmacokinetic analyses and Monte Carlo dosing simulations were 26 undertaken using Pmetrics®. 27Results: Thirty adult haematological malignancy patients were recruited with a mean (SD) loading 28 dose, age, total body weight and creatinine clearance of 9.5 (1.9) mg/kg, 63 (12) that administering five loading doses 12-h, stratified by total body weight and creatinine clearance, 36 increased the probability of achieving target concentrations within 72 h. 37Conclusions: To increase the number of patients achieving optimal teicoplanin concentrations an 38 individualised dosing approach, based on body weight and creatinine clearance, is recommended. 39 40