Medication discrepancies among elderly patients discharged from a tertiary hospital: prevalence and risk factors.

1Pharmacy Department, Hospital Queen Elizabeth II, Ministry of Health Malaysia, Kota Kinabalu, Sabah, 2Faculty of Pharmacy, Puncak Alam Campus, Universiti Teknologi MARA, Selangor, 3Geriatric Unit, Department of Medicine, 4Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia Correspondence: Ms Izzati binti Abdul Halim Zaki, Lecturer, Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam Campus, 42300 Bandar Puncak Alam, Selangor, Malaysia. izzatizaki@gmail.com INTRODUCTION One of the methods to prevent medication errors is conducting a medication reconciliation process to detect and correct any medication discrepancies. A medication discrepancy occurs when there is a difference between the drugs in the treatment regimen (in term of dose, route and frequency of administration) during transition from one healthcare personnel or health centre to another. (1) A study conducted in Malaysia showed that 49% of adults discharged from an internal ward had at least one medication discrepancy,(2) while 23.3% of the elderly discharged from a tertiary care hospital in Singapore had a medication discrepancy upon discharge. (3) Medication discrepancies may cause medication errors and potential harm to patients if left uncorrected. They were identified as contributors to the occurrence of adverse drug events in hospitalised and discharged patients. (4) According to Feleke et al, the number of discharge medications, length of hospitalisation and age did not have a statistically significant association with the high number of medication discrepancies. (5) However, other studies found that the number of medications prescribed upon discharge is the major contributor to medication discrepancies. (2,6) It is thus important to identify the factors that may increase the chance of medication discrepancies occurring, especially in the elderly, as they are prone to having multiple comorbidities and several clinic appointments. There are two types of discrepancies: intentional and unintentional. Intentional discrepancies happen due to underlying comorbidities or a change in the drug metabolism of the patient. (7) In contrast, unintentional discrepancies are made accidentally by the prescriber and/or due to lack of documentation in clinical records. (6) In identifying these discrepancies, a medication reconciliation process can be implemented, in which healthcare personnel will record the previous medication history from either the patient or the caregiver to ensure that they have the most updated medication list. Prior to the discharge or transfer of the patient, healthcare personnel will compare the medication list obtained during admission with the medications prescribed. Discrepancies can be minimised in several ways. A standardised formal medication reconciliation programme at every point of care should be able to detect and reduce the number of medication discrepancies, as suggested by Salameh et al.(8) Currently, medication reconciliation is not a common practice among healthcare professionals in Malaysia. Involvement of pharmacists and other healthcare professionals is important to reduce the number of discrepancies. Thus, the present study was conducted to determine the prevalence and risk factors of medication discrepancies at discharge among patients who were admitted to the geriatric ward in a tertiary hospital.