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The Impact of Pharmacists on Transitions of Care

Tuesday, July 26, 2016   (0 Comments)
Posted by: Elizabeth Maynard
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Olivia Stanton-Ameisen, PharmD Candidate 2017

Vilinny Puth, PharmD Candidate 2018

Jennifer Andres, PharmD, BCPS

Temple University School of Pharmacy


Transitions of care (TOC) refers to the process of moving patients between different healthcare settings.1 During transitions, information and/or documentation may not be updated, especially with regard to medications. Discrepancies with patients’ medications can negatively affect overall care.1 Every patient undergoing transition between healthcare settings is at risk of an adverse drug event (ADE). One study found that 19-23% of patients experienced an ADE within 5 weeks of discharge, and about one-third of those ADEs were avoidable.2,3 Patients at greater risk of an ADE are patients with limited health literacy, low income, concomitant disabilities, complex medical or behavioral health conditions, especially those taking more than five medications daily, and/or the elderly.4 The pharmacist is ideally suited to identify patients at risk for ADEs and to make medication safety interventions.

Potential Causes of ADEs During Transitions:5

Errors in obtaining a pre-admission medication history

Errors in discharge orders

Interactions (drug-drug or drug-disease)

Patient or caregiver misunderstanding of discharge medication regimen

Patient or caregiver inability to manage medications

Inadequate monitoring (adverse effects, adherence, drug levels)

Inadequate steps to ensure the patient can afford medications


In 2005, the Joint Commission identified medication reconciliation as a National Patient Safety Goal (NPSG).6 Medication reconciliation is defined as “a process of identifying the most accurate list of all medications a patient is taking and using this list to provide correct medications for patients anywhere within the healthcare system.”7 Medication reconciliation can occur at admission and also at discharge. A systematic review and meta-analysis of pharmacy-led medication reconciliation programs at hospital transitions found a 66% reduction in medication discrepancies when compared with usual care, defined as no intervention or any intervention not made by a pharmacist.6 This illustrates pharmacists’ role in decreasing medication discrepancies and improving care transitions.

A qualitative study by Haynes et al. assessed pharmacists’ recommendations in hospital medication reconciliation and discharge counseling and found that pharmacists considered medication reconciliation to be their most important role in improving transitions of care, most notably through detection of medication errors during admission medication history sessions. Pre-admission medication lists that were provided to pharmacists in this study varied and gave pharmacists an opportunity to identify and avoid potential ADEs.7

Pharmacists can also assist with discharge medication reconciliation. A prospective, cross-sectional pilot study evaluated the impact of a pharmacist performing discharge medication reconciliations, both clinically and financially. The study took place at 2 adult medical/surgical patient care units and spanned a 7 week period. Pharmacists assessed the patients’ discharge medication list for appropriateness and drug interactions. The primary outcome was to evaluate the amount and severity of errors the pharmacist recognized per patient per service. Secondary outcomes involved comparing 7 and 30-day readmission rates for study patients to those from a historical cohort over the 7 week period. Sixty-seven patients had their discharge medications reviewed by pharmacists and 84 errors were discovered. Seventy-five percent of the errors were significant and 6% were serious. The 30-day readmission rate in the study cohort was 18% and the control group was 20%, which was not statistically significant. The net total savings of the interventions, which accounted for the costs of errors and salaries, was $42,300. The authors extrapolated this number to result in an annual saving of $16,415,000 at this institution. There was no difference in the number of interventions between medical and surgery floors which suggests that all types of admissions can benefit from pharmacist medication reconciliation and the service should not only be offered for high risk patients.8 Additionally, most of the pharmacists performing the interventions were residents, which could be a good way to help with the time burden of discharge medication reconciliation.

A barrier to performing discharge medication reconciliations is time. Medication reconciliations can take up to about an hour, and this could interfere with the overall workflow for the pharmacist.9 Sebaaly J et al. had pharmacists supplement medication reconciliation as opposed to performing it. Pharmacists focused on reviewing admission, inpatient, and discharge medication lists which allowed for a timely and effective review.8 This would be good for institutions that do not have enough pharmacy staff to perform medication reconciliation on admission and discharge, and would also ensure that the patients leave on appropriate therapy.

When patients move or transition through healthcare settings, they are vulnerable to potential ADEs, especially when there is a lack of communication and coordination between healthcare providers. With the high occurrence of preventable ADEs and loss of hospital reimbursement if patients are readmitted within 30 days, intervention to decrease the number of post-discharge ADEs is needed. Pharmacists are the ideal healthcare professional to perform discharge medication reconciliation.10 Not only do patients tend to understand how to take their medications better, multiple sources conclude that patients are more adherent and are more satisfied with the whole process.11,12 They are formally trained and experienced in obtaining medication histories and providing discharge counseling and should be utilized as part of the TOC team. With the help of pharmacists, it is possible to prevent ADEs and readmissions.



1.     Splawski J, Minger H. Value of the Pharmacist in the Medication Reconciliation Process. P T. 2016;41(3):176-8.

2.     Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients following discharge from the hospital. Ann Intern Med. 2003;138:161–167.

3.     Forster AJ, Murff HJ. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005;20:317–323.

4.     Hume AL, Kirwin J, Bieber HL, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32(11):326-337.

5.     Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med. 2016;176(4):484-493.

6.     Mekonnen AB, Mclachlan AJ, Brien JA. Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis. J Clin Pharm Ther. 2016;41(2):128-44.

7.     Haynes KT, Oberne A, Cawthon C, Kripalani S. Pharmacists' recommendations to improve care transitions. Ann Pharmacother. 2012;46(9):1152-9.

8.     Sebaaly J, Parsons LB, Pilch NA, Bullington W, Hayes GL, Easterling H. Clinical and Financial Impact of Pharmacist Involvement in Discharge Medication Reconciliation at an Academic Medical Center: A Prospective Pilot Study. Hosp Pharm. 2015;50(6):505-13.

9.     Newman D, Haight R, Hoeft D. Implementation and impact of pharmacists led medication reconciliation and patient education at discharge from an inpatient behavior health unit. Ment Health Clin. 2013;3(1):96.

10. Sarangarm P, London MS, Snowden SS, et al. Impact of pharmacist discharge medication therapy counseling and disease state education: Pharmacist Assisting at Routine Medical Discharge (project PhARMD). Am J Med Qual. 2013;28(4):292-300.

11.  Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44.

12. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Dis Mon. 2002;48(4):239-48.

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