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Corresponding author. Tamara Imfeld-Isenegger. University of Basel, Department of Pharmaceutical Sciences, Pharmaceutical Care Research Group, Petersplatz 14, Postfach 2148, 4001 Basel, Switzerland.
Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, SwitzerlandClinical Pharmacy, Institute of Hospital Pharmacy, Solothurner Spitäler AG, Olten, Switzerland
Hospital Pharmacy, Zuger Kantonsspital AG, Baar, SwitzerlandBasel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention Institute, University of Zurich & University Hospital Zurich, Zurich, Switzerland
Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, SwitzerlandClinical Pharmacy, Institute of Hospital Pharmacy, Solothurner Spitäler AG, Olten, Switzerland
Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, SwitzerlandClinical Pharmacy, Institute of Hospital Pharmacy, Solothurner Spitäler AG, Olten, Switzerland
Hospital stays are often associated with medication changes, which may lead to drug-related problems (DRPs). Medication reconciliation and medication reviews are strategies to detect and resolve DRPs.
Methods
A descriptive cohort study was conducted using DRPs collected during routine pharmacist-led medication reconciliation and medication reviews in the hospital's community pharmacy at discharge (Zug Cantonal Hospital, Switzerland). In a simulation experiment, we retrospectively analysed the detection and resolution possibilities of these DRPs and their dependency on different information sources.
Results
Overall, 6,087 prescriptions were filled in the hospital's community pharmacy (between June 2016 and May 2019). Among 1,352 prescriptions (with ≥ 1 documented DRP) a total of 1,876 DRPs were detected. The retrospective assessment showed that 1,115 DRPs could have been detected by performing simple medication reviews (based on the discharge prescription and the medication history), whereas in the remaining cases, additional clinical and/or patient-specific information would have been needed. In 944 (84.7 %) DRPs, which are detectable by simple medication reviews, the pharmacist would need to consult the prescriber for resolution.
Conclusion
The detection of DRPs is strongly influenced by the information available. These results support models with pre-discharge medication reconciliation and pharmacist-led medication review procedures enabling both comprehensive detection and facilitated resolution of DRPs.
Zusammenfassung
Hintergrund
Spitalaufenthalte gehen oft mit Änderungen der Medikation einher, was zu arzneimittelbezogenen Problemen führen kann. Der Medikationsabgleich (Medication Reconciliation) und Medikationsanalysen sind zwei Strategien um arzneimittelbezogene Probleme (ABP) zu erkennen und zu lösen.
Methoden
Für diese deskriptive Kohortenstudie wurden ABP verwendet, welche während der routinemässig durchgeführten Medikationsabgleiche und Medikationsanalysen in der spitaleigenen öffentlichen Apotheke bei Spitalaustritt erfasst wurden (Zuger Kantonsspital, Schweiz). In einem Simulationsexperiment führten wir unter Verwendung dieser Daten eine retrospektive Analyse durch und beurteilten die Möglichkeit der Erkennung und Lösung von ABP in Abhängigkeit von der Verfügbarkeit unterschiedlicher Informationsquellen.
Ergebnisse
Gesamthaft wurden während der Studienperiode (Juni 2016 - Mai 2019) 6.087 Austrittsrezepte in der spitaleigenen öffentlichen Apotheke eingelöst. Bei 1.352 Austrittsrezepten (mit ≥ 1 Problem) wurden total 1.876 ABP entdeckt. Die retrospektive Analyse zeigte, dass 1.115 dieser Probleme sich mittels einer einfachen Medikationsanalyse (basierend auf dem Austrittsrezept und der Medikamentenhistorie) identifizieren ließen, wohingegen bei den übrigen zusätzliche klinische und/oder patientenspezifische Informationen nötig wären. Bei 944 (84,7%) der Probleme, welche durch eine einfache Medikationsanalyse entdeckt werden können, muss für deren Lösung der verordnende Arzt konsultiert werden.
Schlussfolgerung
Die Identifizierung von ABP ist stark abhängig von den verfügbaren Informationsquellen. Die Resultate dieser Studie unterstützen Modelle mit einem Medikationsabgleich und Medikationsanalysen durch Apotheker/innen vor Spitalentlassung, welche eine umfassende Identifizierung und eine vereinfachte Lösung der ABP ermöglichen.
A hospital stay is commonly associated with multiple medication changes (e.g. initiation or discontinuation, dose adjustment, generic/therapeutic substitution), which may lead to drug-related problems (DRPs)[
]. The Pharmaceutical Care Network Europe (PCNE) defines a DRP as an “event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes” [
Pharmaceutical Care Network, Europe., The definition of drug-related, problems. https://www.pcne.org/working-groups/2/drug-related-problem-classification. Accessed: 31.12.2020. 2009.
]. A systematic review showed that the median prevalence of drug-related hospital readmission was over 20%, and almost 70% of these readmissions were considered preventable[
]. In recent years, healthcare professionals have developed and evaluated various interventions to detect and resolve potential DRPs at hospital discharge, thus avoiding adverse drug events (ADEs)[
]. According to the World Health Organisation, different healthcare professionals are able to perform medication reconciliation (e.g. physicians, pharmacists, nurses, technicians), but ideally pharmacists should be involved in obtaining or validating the complete and accurate medication list of the patients and comparing this list with medication orders[
]. Pharmacist-led medication reconciliation leads to a significantly reduced number of ADE-related hospital readmissions and emergency department visits[
Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis.
]. Based on available information sources, PCNE defined simple, intermediate and advanced medication reviews (Table 1). The detection of DRPs is directly linked to the types and sources of information available for medication reviews[
Pharmaceutical Care Network Europe. PCNE Medication review types and problems that can be detected. 2013. https://www.pcne.org/upload/wc2013/Workshops/WS%201%20PCNE%20Types%20and%20Problems.pdf. Accessed 31.12.2020.
]. In Switzerland, the majority of community pharmacies are able to perform simple and intermediate medication reviews based on the patient's medication history and patient interviews, but have no access to clinical data[
]. At present, conducting systematic pharmacist-led medication reconciliation and medication reviews at transitions of care, and especially at hospital discharge, is not routine practice in the Swiss healthcare system. Therefore, the question emerges on the extent of DRPs that can be identified and solved in the traditional setting of a community pharmacy without a direct link to hospitals and on the added value of a dedicated service from a discharge pharmacy.
This study aimed at assessing whether DRPs identified on discharge prescriptions in a hospital's community pharmacy (with full access to the hospital's electronic health records) would be detectable in a community pharmacy by simple medication reviews based on the patient's medication history only, or if intermediate or advanced medication review with additional clinical and/or patient-specific information would be needed. In addition, it was assessed whether the resolution of the DRPs that were deemed detectable by a simple medication review would require a consultation with the prescriber.
Methods
Study design and setting
This was a simulation experiment based on data from a retrospective, single-centre, descriptive cohort study using routinely collected data from inpatients discharged from the internal medicine unit (n = 65 beds) of the cantonal hospital of Zug, Switzerland between June 1, 2016 and May 31, 2019. The study was approved by the ethics committee of Northwest and Central Switzerland (EKNZ: 2018-01462; 30.08.2018). Patients were included for analysis if they were 18 years or older and filled their discharge prescription in the community pharmacy located within the hospital and with full access to the hospital's electronic health records (called hereafter hospital's community pharmacy). All results were analysed based on single hospital stays because an individual patient could have several hospital stays during the study period. The results reported here are part of a bigger study focusing on the influence of pharmacist-led interventions on the number of DRPs at discharge, which will be published separately. This study focused on DRPs identified in patients filling their discharge prescription in the hospital's community pharmacy (Figure 1). The cantonal hospital Zug routinely offers pharmacist-led medication reconciliation and medication reviews to patients at hospital discharge according to the hospital internal Standard Operating Procedure (SOP). If patients agree, the discharge prescription is transmitted to the hospital's community pharmacy. Based on eight risk factors (≥5 medications prescribed, patient ≥65 years of age, lack of information on therapy duration, prescription of anti-infective therapy, antiepileptic medication, oral anticoagulant, antiplatelet therapy, ≥1 discrepancy between patient's home medication and the discharge prescription), the hospital's community pharmacists stratify the prescriptions into the different levels of risk for DRPs. According to these risk levels, they perform different types of medication reviews: low = 0-1 risk factor (simple medication review), intermediate = 2 risk factors (intermediate medication review), and high = ≥3 risk factors (advanced medication review). In all risk groups, the pharmacists contact the prescriber if the detected DRPs require a clinical decision regarding the patient's treatment. DRPs leading to minor therapy changes (e.g. optimisation of the intake time, generic substitution) or educating patients about their medications do not require contact with the prescriber.
Figure 1Hospital discharge process at the cantonal hospital Zug and study overview. (DRP = drug-related problem, GSASA = Swiss Society of Public Health Administration and Hospital Pharmacists).
DRPs detected during medication reconciliation and medication reviews at discharge are documented and classified by the hospital's community pharmacists of the cantonal hospital Zug using an adapted version of the GSASA (Swiss Society of Public Health Administration and Hospital Pharmacists) classification tool [
], which was originally developed for the documentation of clinical pharmacists’ activities during the patient's hospital stay (detected problems, causes, performed interventions, and outcomes of the intervention). It was adapted by the hospital's community pharmacists to the discharge situation by adding categories for DRPs caused by medication reconciliation issues. The classification tool used to categorise the DRPs in this study consisted of four main categories, thirteen subcategories, and five categories to document the outcomes of the pharmaceutical interventions (Appendix A, Table S1).
Detection and resolution of DRPs
In a simulation experiment, two members of the research team (A.P.H. and T.L.I.-I.), independently assessed for every documented DRP, if it could have been detected by performing simple medication reviews (based on the discharge prescription and the patient's medication history), or only by conducting intermediate/advanced medication reviews based on the discharge prescription, the patient's medication history, clinical information, and/or patient-specific information (Figure 1). In addition, they assessed whether a direct consultation with the prescriber was necessary for the resolution of the DRPs, which were classified as detectable by simple medication reviews. Differences between the two assessors were resolved by discussion and, if necessary, a third member of the research team (H.S.) was consulted.
Data collection and variables
Data sources for patients’ demographic information and medication at admission and discharge were extracted from the hospital's electronic health records. The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes of the patient's diagnoses at hospital discharge were provided by the hospital's clearing office. The information on prescription filling was extracted from the hospital's community pharmacy software. For each patient, the number of Elixhauser comorbidities [
] was calculated using the ICD-10 codes of all recorded diagnoses to measure patient comorbidity. The research team retrospectively identified and documented all medication names and codes of the Anatomical Therapeutic Chemical (ATC) Classification System associated with the DRPs. The different sources of information were linked in the database using unique encrypted identifiers. The research team validated each variable in the database and the output tables prior to the analysis (Appendix A, Figure S1).
Statistical analysis
Statistical analyses were performed using IBM® SPSS® Statistics Version 25 (IBM Corp., Armonk, New York, USA). We considered all inpatient stays with ≥1 DRP at hospital discharge for analysis. Descriptive statistics were used for the baseline characteristics, the documented DRPs, the ATC codes of medications associated with DRPs and the assessment of the detection and resolution of DRPs. Numeric variables were summarised using median and interquartile range (IQR), for categorical variables, frequencies were calculated.
Results
Between June 1, 2016 and May 31, 2019, the discharge prescriptions of 6087 inpatient stays in the medical unit were filled in the hospital's community pharmacy, 15 prescriptions were excluded due to inconclusive documentation of DRPs. Overall, prescriptions from 6072 inpatient stays (4545 individual patients) were used for the analysis.
Table 2 presents the baseline characteristics of all inpatient stays with ≥1 documented DRP at hospital discharge (n = 1352 inpatient stays, 22.3%). In 77.7% (n = 4720) of inpatient stays, the hospital's community pharmacist did not document any DRPs (Appendix A, Table S2).
Table 2Baseline characteristics of the inpatient stays with ≥1 documented DRP at hospital discharge (n = 1352).
Determinants
Values
Female, n (%)
674 (49.9%)
Age at discharge (in years), median (IQR)
79 (70-85)
Emergency admission, n (%)
1245 (92.1%)
Length of hospital stay (in days), median (IQR)
5.3 (3.2-8.1)
Medication
Number of medications recorded at admission, median (IQR)
7 (5-10)
Number of medications prescribed at discharge, median (IQR)
A total of 1876 DRPs (n = 6072 inpatient stays, an average of 0.31 DRPs per inpatient stay) were detected by the hospital's community pharmacists during medication reconciliation and medication reviews in patients filling their discharge prescription (Table 3). The majority of the detected DRPs were classified into the main category “prescribing problem during the hospital stay or at discharge” (n = 1367, 72.9%) followed by DRPs caused by a “medication reconciliation problem at hospital admission” (n = 438, 23.3%), (Table 3). The most frequently detected sub-categories of DRPs were “missing/inappropriate dosage” (n = 409, 21.8%), followed by “omission of a medication” (n = 184, 9.8%), “untreated indication” (n = 182, 9.7%) and “medication not indicated or duplication” (n = 182, 9.7%).
Table 3Number and categories of DRPs detected at hospital discharge by the hospital's community pharmacist (n = 1876) and the number of DRPs leading to a modification in the discharge prescription.
Main category and sub-category
Frequency of DRPs
Frequency of DRPs leading to modifications in the discharge prescription
Number
Number (%)
1) Medication reconciliation problem at hospital admission
438
319 (72.8%)
1.1 Incorrect medication recorded
114
100
1.2 Omission of a medication
184
105
1.3 Incorrect strength/dose recorded
140
114
2) Prescribing problem during the hospital stay or at discharge
1367
1012 (74.0%)
2.1 Incorrect or lack of substitution back to patient's home medication
136
127
2.2 No restart of medication that was paused during the hospital stay
58
52
2.3 Missing/inappropriate dosage
409
304
2.4 Missing/inappropriate therapy duration
135
121
2.5 Medication not indicated or duplication
182
116
2.6 Untreated indication
182
144
2.7 No concordance with guideline or contraindication
46
22
2.8 Interaction
98
67
2.9 Adverse effect
29
14
2.10 Medication not suitable or of limited suitability
Table 3 shows that 71.6% (n = 1344) of the detected DRPs led to a modification of the original discharge prescription. In 10.9% (n = 204) of cases, the prescriber was informed about the DRP, but the result of the intervention was not followed up. In 6.8% (n = 128) of cases, a recommendation concerning medication was made to the patients’ general practitioner in the hospital discharge letter. Additionally, in 6.5% (n = 122) of cases, the pharmaceutical interventions triggered by the DRPs were not accepted by the prescribing physician, and in 3.6% (n = 67) of cases, the patient was directly informed by the hospital's community pharmacist about the DRP because no prescriber approval and/or notification was deemed necessary.
The ten most frequent ATC subgroups associated with the detected DRPs were: proton pump inhibitors (n = 136), HMG-CoA-reductase inhibitors (n = 135), direct factor Xa inhibitors (n = 105), calcium, combinations with vitamin D and/or other drugs (n = 94), selective beta-blocking agents (n = 92), ACE inhibitors (n = 91), platelet aggregation inhibitors excluding heparin (n = 80), angiotensin II receptor blockers (n = 77), sulphonamides (n = 75), and dihydropyridine derivatives (n = 66). Illustrative examples of DRPs detected at hospital discharge are shown in Appendix A, Table S1.
Detection and resolution of DRPs
In a simulation experiment, two members of the research team retrospectively assessed detectability and resolvability of 1852 DRPs (98.7%), 24 DRPs were excluded due to inconclusive documentation of the problem. Figure 2 shows that community pharmacists conducting simple medication reviews (based on discharge prescriptions and medication history only) would be able to detect 1115 out of the 1852 DRPs (60.2%), whereas for the detection of the remaining DRPs (n = 737, 39.8%), additional clinical and/or patient-specific information is needed. Focusing on the 1115 DRPs, which are detectable by simple medication reviews, Figure 3 shows that 944 (84.7%) DRPs would require a consultation with the prescriber for the resolution of the problem. Examples for DRPs detectable by simple medication reviews and resolvable without prescriber consultation (n = 171) are inadequate medication intake time or suboptimal frequency, intake of fluoroquinolone/bisphosphonate/levothyroxine with polyvalent cations, or incorrect/lack of generic substitution in accordance with the patient's home medications. In contrast, DRPs detectable by simple medication reviews requiring contact with the prescriber for resolution (n = 944) include, e.g., prescription of multiple medications associated with QT-interval prolongation, missing/inappropriate therapy duration of antibiotics/antifungals, or untraceable changes in the patient's medication (e.g. discontinuation of medications for chronic conditions), because these DRPs require clarification and/or a clinical decision regarding the patient's treatment.
Figure 2Detection of DRPs in a simulation experiment by performing either simple or intermediate/advanced medication reviews at hospital discharge (n = 1852 DRPs).
Figure 3Resolution of DRPs detected in a simulated experiment by simple medication reviews with or without the consultation of the prescriber (n = 1115).
This study aimed to assess the influence of the availability of different information sources on the detectability of DRPs, and whether resolving the DRPs detected by simple medication review would require a consultation with the prescriber or not. Our findings suggest that pharmacists without access to clinical and/or patient-specific information can only detect a part of the DRPs at hospital discharge. For many cases, additional clinical and/or patient-specific information is needed. The access to patient-specific information collected during a patient interview helps to detect adherence issues, medication use problems, knowledge gaps, and adverse drug reactions[
Pharmaceutical Care Network Europe. PCNE Medication review types and problems that can be detected. 2013. https://www.pcne.org/upload/wc2013/Workshops/WS%201%20PCNE%20Types%20and%20Problems.pdf. Accessed 31.12.2020.
]. Since patients are often present when prescriptions are filled, they might be a reasonable source of information for the identification of DRPs after hospital discharge in the community pharmacy. Conversely, for the detection of, for example, incorrect dosing according to organ dysfunction, a medication without documented indication, or a diagnosis without treatment, pharmacists need access to clinical patient information[
Pharmaceutical Care Network Europe. PCNE Medication review types and problems that can be detected. 2013. https://www.pcne.org/upload/wc2013/Workshops/WS%201%20PCNE%20Types%20and%20Problems.pdf. Accessed 31.12.2020.
]. However, in some European countries and in most community pharmacies in Switzerland, clinical patient information is not routinely accessible by pharmacists[
]. Therefore, the access to hospital discharge summaries, including clinical patient information, could be beneficial for the detection of DRPs by community pharmacists, reduce the risk for undetected DRPs [
], which is also common practice in Switzerland. The implementation of shared electronic patient records accessible by all involved healthcare providers might be a valuable option to increase the quality of patient care[
]. Taking all of this into consideration, both the access to patient-specific information, as well as clinical patient information, is desirable in community pharmacies to enable comprehensive detection of DRPs in patients after hospital discharge.
Nonetheless, the detection of DRPs is only the first step of the process. Pharmacists need to clarify and resolve DRPs, either by themselves or in collaboration with the prescriber. We found the majority of DRPs detectable by simple medication reviews would require a consultation with the prescriber for their resolution. One study from the Netherlands analysed 100 hospital discharges in the community pharmacy and investigated the medication discrepancies between discharge documents and documentation in community pharmacy software for discharged patients, and the number of discharges causing contact with the physician[
]. These results show that community pharmacists frequently contact prescribers to discuss DRPs in patients discharged from the hospital. Additionally, it should be taken into account that each contact with the prescriber leads to an interruption of workflow [
]. The collaborative preparation of discharge prescriptions by physicians and pharmacists within the hospital could lead to a reduction in the number of DRPs in patients discharged from the hospital, which would increase medication safety as well as save time.
In addition, the results of the present study confirm previous findings indicating the frequent occurrence of DRPs at hospital discharge. Over 70% (n = 1367) of the detected DRPs were caused by prescribing problems during the hospital stay or at hospital discharge. In contrast, 23% (n = 438) of the DRPs were caused by a medication reconciliation problem at hospital admission. The most frequent DRP sub-category within this main category was the omission of a medication that the patient was taking prior to hospitalisation, followed by the recording of incorrect medication doses or strengths. Previous national and international studies performing medication reconciliation at hospital admission showed a similar pattern of DRPs[
]. The persistence of these DRPs from admission throughout the hospital stay and at discharge may lead to further reconciliation errors at subsequent transitions of care[
Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.
]. Therefore, a systematic pharmacist-led medication reconciliation process at hospital admission constitutes a valuable opportunity to reduce these types of DRPs[
Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission.
]. So far, this is not common practice upon hospital admission in Switzerland.
Strengths and limitations
The strengths of this study were its large sample size and the use of routinely collected data, which was not influenced by a highly controlled and artificial study environment.
However, the limitations of this study should be taken into account when interpreting the results. We analysed data from a single site. Nevertheless, this hospital's community pharmacy was performing comprehensive patient discharge management, which is not routinely established in Swiss hospitals so far and might be an example for other institutions. The risk stratification including eight different risk factors could influence the pattern of the DRPs, but the comparison of the DRPs detected in our study was similar to other national and international studies[
]. Furthermore, the analysis of routinely collected real-life data might result in a slight underestimation of DRPs, because in daily practice minor problems and interventions might not have been comprehensively documented in the hospital's community pharmacy. Several pharmacists performed medication reconciliation and medication reviews, which might lead to heterogeneity in the detection and classification of the DRPs. Additionally, this was a retrospective assessment of DRP detection and resolution possibilities based on a simulation experiment, performed by two members of the research team not working at the study site.
Conclusion
The ability to detect DRPs is strongly influenced by the extent of information available to the pharmacists. While simple medication reviews enable the detection of approximately 60% of all DRPs identified by pharmacists at discharge, a majority of these DRPs would require a consultation with the prescriber for resolution. These results support the added value of a dedicated service from a discharge pharmacy or models with pre-discharge medication reconciliation and pharmacist-led medication review procedures enabling both, comprehensive detection and facilitated resolution of DRPs through easy access to clinical data and contacts to the prescribers. However, with regard to the community pharmacy setting, we advocate full access to hospital health records and efficient communication channels between healthcare professionals to reduce inadequate post-hospital medication therapies, save resources by reducing consultations between pharmacists and prescribers, which might ultimately improve patient safety and clinical outcomes.
Funding
This study was partially funded by the research grant of the Swiss Association of Public Health Administration and Hospital Pharmacists (GSASA), 2018. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Ethics approval
The study was approved by the ethics committee of Northwest and Central Switzerland (EKNZ: 2018-01462; 30.08.2018).
Acknowledgement
We would like to thank all the pharmacists of the cantonal hospital Zug, who detected and documented the DRPs at hospital discharge. Furthermore, we thank Simon Studer for the support in data management and William Caddy for proofreading the manuscript.
Conflict of interest
The authors have declared that no competing interests exist.
CRediT author statement
Tamara L. Imfeld-Isenegger: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Writing - Review & Editing, Visualization, Project administration, Funding acquisition. Helene Studer: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Data Curation, Writing - Review & Editing, Project administration, Funding acquisition. Marco G. Ceppi: Conceptualization, Methodology, Resources, Writing - Review & Editing, Funding acquisition. Christoph Rosen: Conceptualization, Methodology, Resources, Data Curation, Writing - Review & Editing, Funding acquisition. Michael Bodmer: Conceptualization, Resources, Writing - Review & Editing. Patrick E. Beeler: Methodology, Software, Formal analysis, Writing - Review & Editing. Fabienne Boeni: Conceptualization, Methodology, Writing - Review & Editing, Funding acquisition. Armella P. Häring: Formal analysis, Writing - Review & Editing,. Kurt E. Hersberger: Conceptualization, Methodology, Resources, Writing - Review & Editing, Supervision, Funding acquisition. Markus L. Lampert: Conceptualization, Methodology, Resources, Data Curation, Writing - Review & Editing, Supervision, Funding acquisition.
Pharmaceutical Care Network, Europe., The definition of drug-related, problems. https://www.pcne.org/working-groups/2/drug-related-problem-classification. Accessed: 31.12.2020. 2009.
Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis.
Pharmaceutical Care Network Europe. PCNE Medication review types and problems that can be detected. 2013. https://www.pcne.org/upload/wc2013/Workshops/WS%201%20PCNE%20Types%20and%20Problems.pdf. Accessed 31.12.2020.
Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.
Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission.
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