Introduction: Medication discrepancies can lead to serious consequences, and is more likely to occur in elderly patients and patients with chronic disorders due to polypharmacy. Such errors can contribute to drug-related problems, medication errors, adverse drug events and jeopardise patients’ health. The discharge period is a particularly vulnerable transitional interface as there is a higher risk of these dis- crepancies. The aim of this study was to assess the incidence of unintentional medication discrepancies during discharge of patients admitted to the medical wards of a tertiary referral centre. Materials and Methods: Data was prospectively collected over a period of three months (21st March to 21st June 2011). All the discharge prescriptions were carefully checked for errors: unintentional missed medica- tion, inappropriate or missing dose and unexplained dosage increase or reduction which required inter- vention, missing or inappropriate duration, illegible handwriting and inappropriate formulation. The types of pharmacy intervention were classified into ‘error’, ‘near-miss’ and ‘confirming’. Error is when a particular event had occurred in the ward prior to pharmacy intervention, near-miss is when there was intervention before a particular event had occurred, and an intervention was classed as ‘confirming’ when no changes were made in the actual prescriptions after pharmacy intervention. Results: There was a total of 845 discharge prescriptions consisting of 5,465 medications encountered during the study period. Overall, 18.7% (n=158) of the prescriptions required intervention, ranging from 11.8% to 22% per ward. The most common interventions was for unintended missed medications and dosage adjustments. Overall, 3% of all intervention required was classified as error whereas 49% classified as near-miss. Prescriptions from the Nephrology services required the most intervention. Conclusions: This study demonstrated the importance of conducting a medication reconciliation process in ensuring patients are discharged with the appropriate and correct medications. It is an effective way of reducing medication discrepancies and is an essential process for optimizing the safe and effective use of medi- cines.