International Journal of Clinical Pharmacy

, Volume 35, Issue 6, pp 1083–1090 | Cite as

Pharmacist-led medication reconciliation to reduce discrepancies in transitions of care in Spain

  • Maria Ángeles Allende BandrésEmail author
  • Mercedes Arenere Mendoza
  • Fernando Gutiérrez Nicolás
  • Miguel Ángel Calleja Hernández
  • Fernando Ruiz La Iglesia
Research Article


Background Medication errors are one of the main causes of morbidity amongst hospital inpatients. More than half of medication errors occur at ‘interfaces of care’, when patients are discharged or transferred to the care of another physician. Medication reconciliation is the process of reviewing patients’ complete previous medication regimen, comparing it with current prescriptions, and analysing and resolving any discrepancies that the pharmacist does not believe to be intentional (unjustified discrepancies). Objective To quantify and analyse reconciliation unjustified discrepancies detected by a pharmacist in patients admitted to an internal medicine unit (IMU) over a 3-year period. Setting and method The hospital employs a pharmacist who acts as a link between the primary care services and the internal medicine specialist care unit. A retrospective descriptive study on the reconciliation discrepancies found was carried out. Medication reconciliation was performed upon admission in all patients transferred from the Accident and Emergency department (A&E) and admitted to the IMU, and also at the time of discharge. The interventions were categorised based on the consensus document on terminology and medication classification published by the Spanish Society of Hospital Pharmacy. Main outcome measure Number of patients with unjustified discrepancies, also known as reconciliation errors. Results 2,473 patients had their treatment reviewed at the time of admission and 1,150 at discharge. 866 reconciliation discrepancies were detected in 446 patients (1.94 per patient). 807 (93 %) were accepted by the prescribing physician and classified as reconciliation errors. 16.8 % of patients had at least one reconciliation error: 63.8 % of these errors were incomplete prescriptions, 16.6 % were medication omissions and 10.5 % were errors in dosage, administration method and/or frequency. Conclusion The rate of medication errors found in this study is low compared with other similar studies. The most common error was “incomplete prescriptions”, most of them generated by the Accident and Emergency department. A computerised clinical history would help to decrease the number of reconciliation errors. Pharmacist interventions focused on medication reconciliation are well accepted by physicians, improving the quality of clinical histories and decreasing the number of medication errors that occur across transitions in patient care.


Chronic medication Clinical safety Medication errors Medication reconciliation Pharmaceutical care Spain 



We would like to thank the physicians in the Internal Medicine Unit on the 12th floor of the Lozano Blesa Clinical Hospital in Zaragoza for all their help with the day-to-day work involved in this study, which would not have been possible without their cooperation.


This project was funded with cohesion funds provided by the Autonomous Region of Aragon.

Conflicts of interest



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Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2013

Authors and Affiliations

  • Maria Ángeles Allende Bandrés
    • 1
    Email author
  • Mercedes Arenere Mendoza
    • 2
  • Fernando Gutiérrez Nicolás
    • 3
  • Miguel Ángel Calleja Hernández
    • 4
  • Fernando Ruiz La Iglesia
    • 5
  1. 1.Pharmacy DepartmentLozano Blesa Clinical HospitalSaragossaSpain
  2. 2.Pharmacy DepartmentNuestra Señora del Pilar Psychosocial Rehabilitation CentreSaragossaSpain
  3. 3.Pharmacy DepartmentCanary Islands University Hospital, Institute of Tropical Diseases and Public Health of the Canary IslandsTenerifeSpain
  4. 4.Pharmacy DepartmentVirgen de las Nieves University HospitalGranadaSpain
  5. 5.Internal Medicine DepartmentLozano Blesa Clinical HospitalSaragossaSpain

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