Study to Assess the Impact of Medication Reconciliation at Hospital Admission on Healthcare Outcomes

Patients of the control group will not receive the best possible medication history with medication reconciliation at admission. The standard physician‐acquired medication history will be performed as usual. Eligible patients, randomized within the intervention arm, will receive medication reconciliation according to the following steps: 1. The pharmacy assistant will obtain the best possible medication history by compiling a comprehensive list of the medications the patient is taking and details about how the drugs are taken. In order to confirm the accuracy of the history, the pharmacy assistant will use at least two sources of information, one of which being, when possible, the interview with the patient and/or family members, in addition to referral letters, prescriptions and drug lists from primary care centres, and other. 2. The clinical pharmacist will reconcile best possible medication history with prescribed medicines and, to resolve unclear or ambiguous discrepancies between the two lists and/or to propose any adaptations of the pharmacotherapy, the clinical pharmacist will refer to the medical doctor. 3. The medical doctor will decide potential changes in pharmacotherapy and communicate them to the patient providing complete information on medicines.