Pharmacists Positioned to Improve Care Transitions

Greater pharmacist involvement in care transitions could curb the many medication discrepancies that arise throughout the process.

In a recent case study, 17 patients at high risk for medication mishaps during transitions of care from inpatient to outpatient settings were called soon after discharge and asked to provide information on all medications they were taking.

The resultant patient-reported medication lists were compared with the patients’ discharge summaries, and any medication discrepancies discovered were categorized as patient- or system-level factors.

The study authors identified 96 medication discrepancies across just these 17 patients. More than two-thirds of the discrepancies involved a prescribed drug omitted from patient-reported medication lists or discharge summaries, and most of them were related to patients resuming medications that were not listed on the discharge instructions.

About half of the patients had at least 1 discrepancy associated with a patient-level factor, the most common of which was medication nonadherence.

More alarmingly, all patients had at least 1 medication discrepancy related to system-level factors such as incomplete discharge instructions or incorrect drug dosage or frequency—a finding that lead author Jessica M. Downes, PharmD, BCACP said “raises real concerns about how medication use is managed as discharged patients transition to outpatient care.”

“Medication discrepancies that arise during [transitions of care] are often associated with increased adverse events and hospital readmissions. That’s why it’s so important to ensure that pharmacists—the medication experts—are part of patients’ care teams,” stated AJHP Editor-in-Chief Daniel J. Cobaugh, PharmD, DABAT, FAACT.

Echoing his remark, the study authors said their findings demonstrate the need for pharmacists to be more involved in care transitions to ensure medication adherence and prevent adverse effects.

Importantly, pharmacists in this study were not positioned to assume a formal role in the discharge process, according to Dr. Downes.

However, a previous study involving a pharmacist-led transitions-of-care program proved that pharmacy staff can successfully take the lead in improving care transitions, at least for heart failure patients. Other studies have shown that pharmacist-led interventions support patient adherence to new oral anticoagulants, which improves health outcomes.

“Pharmacists are integral within the [health care] team in order to evaluate the appropriateness of medication use, to ensure information is updated in the health record, and to verbally communicate accurate information to other health professionals,” wrote the authors of yet another similar study. “…It is vital that pharmacists encourage patients, family members, and caregivers to be involved with the medication reconciliation process as active members of the health care team.”

The current case study was published in the September 1, 2015, issue of the AJHP Residents Edition.