To evaluate the clinical pharmacist-led medication reconciliation process in clinical practice by quantifying and analyzing unintentional medication discrepancies at hospital admission. An observational prospective study was conducted at the Clinical Department of Internal Medicine, University Hospital Dubrava, during a 1-year period (October 2014 - September 2015) as a part of the implementation of Safe Clinical Practice, Medication Reconciliation of the European Network for Patient Safety and Quality of Care Joint Action (PASQ JA) project. Patients older than 18 years taking at least one regular prescription medication were eligible for inclusion. Discrepancies between pharmacists' Best Possible Medication History (BPMH) and physicians' admission orders were detected and communicated directly to the physicians to clarify whether the observed changes in therapy were intentional or unintentional. All discrepancies were discussed by an expert panel and classified according to their potential to cause harm. In 411 patients included in the study, 1200 medication discrepancies were identified, with 202 (16.8%) being unintentional. One or more unintentional medication discrepancy was found in 148 (35%) patients. The most frequent type of unintentional medication discrepancy was drug omission (63.9%) followed by an incorrect dose (24.2%). More than half (59.9%) of the identified unintentional medication discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration in the patient. Around 60% of medication errors were assessed as having the potential to threaten the patient safety. Clinical pharmacist-led medication reconciliation was shown to be an important tool in detecting medication discrepancies and preventing adverse patient outcomes. This standardized medication reconciliation process may be widely applicable to other health care organizations and clinical settings.

What is known and Objective There is no optimal standardized model in the transfer of care between hospitals and primary healthcare facilities. Transfer of care is a critical point during which unintentional discrepancies, that can jeopardize pharmacotherapy outcomes, can occur. The objective was to determine the effect that an integrated medication reconciliation model has on the reduction of the number of post‐discharge unintentional discrepancies. Methods A randomized controlled study was conducted on an elderly patient population. The intervention group of patients received a medication reconciliation model, led entirely by a hospital clinical pharmacist (medication reconciliation at admission, review and optimization of pharmacotherapy during hospitalization, patient education and counselling, medication reconciliation at discharge, medication reconciliation as part of primary health care in collaboration with a primary care physician and a community pharmacist). Unintentional discrepancies were identified by comparing the medications listed on the discharge summary with the first list of medications prescribed and issued at primary care level, immediately after discharge. The main outcome measures were incidence, type and potential severity of post‐discharge unintentional discrepancies. Results and discussion A total of 353 patients were analysed (182 in the intervention and 171 in the control group). The medication reconciliation model, led by a hospital clinical pharmacist, significantly reduced the number of patients with unintentional discrepancies by 57.1% (p < 0.001). The intervention reduced the number of patients with unintentional discrepancies associated with a potential moderate harm by 58.6% (p < 0.001) and those associated with a potential severe harm by 68.6% (p = 0.039). The most common discrepancies were incorrect dosage, drug omission and drug commission. Cardiovascular medications were most commonly involved in unintentional discrepancies. What is new and Conclusion The integrated medication reconciliation model, led by a hospital clinical pharmacist in collaboration with all health professionals involved in the patient's pharmacotherapy and treatment, significantly reduced unintentional discrepancies in the transfer of care.

Mental health is an important segment in preserving overall health and represents a significant public health issue. In modern times, mental health disorders have risen, often requiring complex pharmacotherapy and chronic monitoring. The aim of this research was to determine the prevalence and clinical significance of potential psychotropic drug interactions in outpatient settings and compare the differences in potential drug–drug interaction (pDDIs) exposure with age. The psychotropic drugs included antipsychotics—N05A, anxiolytics—N05B, hypnotics and sedatives—N05C, and antidepressants—N06A. This retrospective study analyzed prescribed pharmacotherapy in 492 outpatients who were treated with at least one psychotropic drug. We determined 1.64 prescribed psychotropic drugs per patient and 2.2 pDDIs that involved psychotropic drugs. In total, 2285 pDDIs were recorded, of which almost half (47.6%) were pDDIs with psychotropic drugs. More prescribed psychotropic drugs were found in patients younger than 65 years, and equal exposure to pDDIs of psychotropic drugs (p = 0.5077) was found in both age groups. The most commonly identified psychotropics involved in pDDIs were benzodiazepines, promazine, and zolpidem. The results indicate that psychotropic drug interactions represent important drug-related problems for primary health care. The widespread use of psychotropic drugs and the determined clinical significance of their interactions require pharmacist interventions which can reduce the prevalence of pDDIs and increase patient safety.

Antimicrobial consumption is increasing. In order to maximize the effectiveness of antimicrobial stewardship and provide safe and optimal use of restricted antimicrobial drugs, renal dosing should be evaluated. The aim of this study was to determine the prevalence of restricted antimicrobial drugs that required dose adjustment according to renal function. A retrospective, consecutive study was conducted at University Hospital Dubrava. This study analyzed requests for restricted antimicrobial drugs (n = 2890) during a 3-month period. Requests for antimicrobial agents were evaluated by the antimicrobial therapy management team (A-team). This study included 412 restricted antimicrobial drug requests requiring dose adjustment, of which 39.1% did not have an adjusted dose. Meropenem, Ciprofloxacin, Piperacillin/Tazobactam, Vancomycin, Colistin and the antimycotic Fluconazole were the most frequent restricted antimicrobial drugs that required dose adjustment according to impaired renal function. The results of this research highlight the importance of the A-team in the optimization of restricted antimicrobial therapy. Non-adjusted doses of restricted antimicrobial drugs increase the possibility of adverse drug reactions and therefore jeopardize pharmacotherapy outcomes and patient safety.

Cardiovascular diseases (CVDs) are the leading cause of mortality and morbidity globally. It is estimated that 17.9 million people died from CVDs in 2019, which represents 32 % of all deaths worldwide. Cardiovascular drugs are the most common medical intervention for the prevention of cardiovascular events. CV medications have many benefits however their application is often complicated by multimorbidity and polypharmacy. Drug-drug interactions (DDIs) can lead to adverse drug events, hospitalizations, prolonged hospital stays, increased healthcare costs, and increased risk of mortality. Hospital admission provides an opportunity for pharmacotherapy analysis and for identifying DDIs which can jeopardize medication safety. The aim of this study is to determine the type and prevalence of potential clinically significant DDIs in patients with CVD and to examine factors associated with exposure to DDIs. A prospective study was conducted at the Dubrava University Hospital at the Clinic of Cardiology during a 6-month period (September 2023 – February 2024). Demographic, clinical and pharmacotherapy data were collected for each patient. The first prescribed pharmacotherapy was analyzed. The research was approved by the Hospital’s Ethics Committee and each patient involved in the study signed an informed consent. Lexicomp ^® Lexi-InteractTM Online (Lexi-Comp, Inc., USA) was used for DDI analysis. Poisson regression was used for regression analysis for determining risk factors associated with exposure to DDIs. Total of 151 patients admitted to Cardiology ward were included in the research, and the average age was 67 years. Patients had an average of 9 medications in their therapy and 8 diagnoses. Overall, 1268 potential clinically significant DDIs were determined, of which the most frequently determined interactions were grade C (90.9 %), then grade D (8.6 %) and grade X (0.6 %). CV medications were involved in 88 % DDIs. The most common interventions regarding identified DDIs included exclusion one of the drugs, dose adjustment, increased monitoring of signs of bleeding, cardiac disorders, hypoglycemia, CNS depression and rhabdomyolysis, blood pressure, markers of renal function and electrolyte status. Factors associated with the prevalence of potential clinically significant DDIs were decreased renal function, recent hospitalization, total number of comorbidities and polypharmacy. Specific comorbidities associated with DDIs were arrhythmia, heart failure, diabetes mellitus and disease of the respiratory system. A high prevalence of DDIs of CV medications in all categories of clinical significance was determined. Managing medication safety in specific patient groups with CVDs can represent a greater challenge regarding DDIs. Certain medical conditions, such as arrhythmia, heart failure, diabetes, and diseases of the respiratory system, multimorbidity, polypharmacy, impaired renal function and recent hospitalization are identified in this research as additional factors associated with DDIs occurrence in patients with CVDs at hospital admission. Hospital admission is one of the crucial points for managing medication safety. Clinical pharmacists should regularly analyze DDIs in prescribed pharmaco-therapy which enhances medication safety and also contributes to the quality of provided health care.