• medicazion reconciliation
• riconciliazione farmacologica
• rischio clinico

Poor communication and inadvertent information loss is the main cause of medication discrepancies between recommended treatment and actual outpatient medication use. As a consequence, medication errors represents one of the primary cause of discharge-related adverse drug events and patient readmission in hospital. Medication reconciliation (MedRec) objective is to ensure that accurate and comprehensive medication information is provided constantly to the patient across transitions of care. The cooperation between health care professionals has a remarkable role in preventing medication discrepancies. The MedRec study coordinated by the UO Farmaceutica Ospedaliera, Fondazione Toscana Gabriele Monasterio (FTGM), in collaboration with Regione Toscana, Gestione Rischio Clinico and Agenzia regionale di sanità della Toscana, is focused on analysis of different ways to record pre-admission medication list and identification of discrepancies at care transitions. We identified patients admitted to Cardiothoracic Dept at FTGM between January and March 2013, taking at least four drugs. We reviewed methods used at admission to report therapy. Discrepancies between therapy at admission and physicians’ admission medication orders were assessed with a two-step indipendent review by a pharmacist and a physician. We also compared the discharge prescriptions and the drugs reimbursed to patients by the Regional Healthcare Service throughout 9 months after discharge.