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.

Introduction: Surgical site infections (SSI) are common healthcare associated infections (HAI) that is associated with increased morbidity and cost. Antimicrobial prophylaxis is effective when used appropriately. This study assesses the prophylactic antimicrobial prescribing and practice in the orthopaedic wards based on the Scottish Intercollegiate Guidelines Network (SIGN) guideline on antibiotic prophylaxis in surgery. Materials and Methods: Patients admitted to the Orthopaedics wards over a four-week period were studied (n = 68). Criterions 1 to 4; appropriateness, choice of antimicrobial and route of administration (1- given when indicated, 2- not given when not indicated, 3- appropriate choice and 4- given intravenously), criterions 5 to 7; allergy status and documentation (5: documentation, 6- details and 7- definite or possible history reaction immediately after penicillin therapy should not receive prophylaxis with a beta-lactam antimicrobial), criterions 8 to 10; documentation of antimicrobial given (8- name, dose and route of administration, 9- documentation in the appropriate 'one-off' section of the drug chart and 10- documentation of time of administration and surgical incision) and criterion 11 to 14; time and doses required (11- prophylaxis should be given 30 minutes before surgery, 12- additional intra-operative dose not required, 13- post-operative doses of prophylaxis not given and 14- a 24 hours regimen of prophylactic antimicrobial is given for primary arthroplasty procedures). A simple scoring system was used to allocate level of appropriateness. The rate was considered 'very good' for above 85%, 'good' for 70%-85%, 'moderate' for 50%-69%, 'poor' for 30%-49% and 'very poor' for below 30%. Results: The overall conformation to criteria and standards was 66.4% (95% CI 61.7-70.7). The rates were rated as 'very good' for criterion 1, 3, 4, 5b, 6, 8 and 9, 'good' for criterion 5a and 'poor' for criterions 2 and 5c. The adherence rates were 'very poor' to criterion 10a, 10b, 13 and 14. Intravenous cefuroxime was used as the first choice for antimicrobial prophylaxis. Conclusions: The overall practice was moderate and the choice of drug was considered appropriate. However, certain areas such as documentation need improvement. A local guideline may be useful.
Antimicrobial ; Orthopaedic Surgery ; Surgical Site Infection