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Objectives Medication review consists of a structured evaluation of the patient‘s treatment, with the objective of increasing health benefits and minimizing the risks associated with the medication. The review includes prevention, identification, notification and resolution of medication-related problems (MRPs). To describe the application in the clinical practice of a new electronic tool developed to improve the medical treatment reconciliation and medical review made by pharmacists in healthcare transitions. Method ‘Observa’ (Observatory of the medication safety) is a new collaborative work web environment that allows a communication linked to the electronic medication lists and medical records between clinical pharmacists and physicians. Besides, it provides clinical decision support about interactions, contraindications, duplicities, anticholinergic load and potentially inappropriate drugs in elders. Pharmacists perform the medication reconciliation at hospital admission and discharge and, in primary care, they are responsible for reviewing the treatments of patients that have not been admitted to hospital in the last year. Through this tool, pharmacists assess the adequacy of the pharmacotherapy considering aspects such as drug related adverse events, prescription errors, high-risk medications, drugs without indication, interactions, contraindications, redundant treatments, dose adjustment in renal failure and anticholinergic load. These proposals are directed to physicians through electronic health records and they can accept, reject or postpone them. Results A 15 months retrospective analysis was performed. A total of 9920 proposals were registered; 167 detected during individual medication review, 37 during reconciliation and 9716 massive discontinuation proposals included in the intervention strategies. A total of 110 proposals were sent to doctors: 41.8% were accepted, 12.7% were rejected and 45.5% were pending at the moment of the analysis. Around 1110 clinical questions and answers related to patient treatments were registered. Conclusions Medication reconciliation and review is a priority process that enhances significantly patients´ safety. Observa facilitates the pharmacotherapeutic management during the continuity of health care process, and promotes the pharmacist´s clinical activity. |
