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Background: Transitions of care pose special challenges for everyone involved in the healthcare system. The interface between outpatient and inpatient care is particularly prone to errors. This can be seen from the fact that, according to a systematic review, up to 67% of patients have at least one unintended medication discrepancy (UMD) in their medication history upon hospital admission [1]. Older patients in particular are at risk due to their comorbidities and the resulting drug therapy.

Materials and Methods: A two-part study investigated the frequency and severity of UMDs in a German hospital. As part of a prospective cohort study, 100 participants over the age of 65 who regularly took at least three medications were included, and the frequency of UMD in medication history during elective hospital admission to the urology department at Helios Klinikum Krefeld was examined. After the medical recording of premedication was completed, the best possible medication history (BPMH) was collected by a pharmacist and the information concerning UMD was compared.

In the following prospective, randomized controlled intervention study, the influence of a pharmaceutical intervention on the occurrence of UMD was investigated. Forty-three participants received the standard procedure (comparable to the prospective cohort study). In the intervention group (n = 43), the best possible medication history was recorded in the electronic patient file. The medical staff checked, supplemented, and, if necessary, changed the inpatient medication after appropriate review.

Results: 72% of medication histories in urology showed at least one unintended discrepancy. 60% of participants had errors in prescription medication that was taken on a long-term basis. In the intervention group the proportion of patients with at least one UMD was reduced from 60.5% to 14.0% (p < 0.001; odds ratio 9.431, CI 95% 3.277–27.148). Compared to usual medication use in the outpatient sector, medications were particularly often accidentally forgotten, added, or dosages changed. In both studies, more than half of the UMDs were of potential clinical relevance if the discrepancy had reached the patient (NCC MERP category D–I).

Conclusion: When taking a medication history upon admission to hospital, unintended discrepancies occur regularly, leading to errors in the continuation of medication. The comprehensive deployment of pharmaceutical staff can significantly reduce unintended errors. The impact on patient-relevant factors such as mortality and readmissions should be subject of future work [2].

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