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Background The period 7 to 10 days following hospital discharge is associated with a significant risk of medication misadventure, especially in high‐risk patients. Aim To investigate whether post‐discharge hospital‐initiated medication review (HIMR) pathways are more timely than the post‐discharge home medicines review (HMR) pathway. Method An implementation study conducted over 9 months in 2008/2009 of patients from 3 South Australian hospitals. A risk stratification instrument was used to identify patients at “high” risk of medication misadventure. Feasibility was assessed and time to conduct the post‐discharge medication reviews was determined for the HMR and HIMR pathways. Results Of the 97 consenting patients, 92 were stratified as “high” risk. HIMR were organised for 59 patients − 52 patients completed the HIMR process. Of the 22 HMRs organised via the patient's general practitioner, 18 patients completed the HMR process. The time from request to conducting the HIMR and HMR were statistically significantly different – HIMR and HMR took 6.5 ± 4.7 days and 11 ± 7.4 days, respectively (p = 0.02). Conclusion This study has demonstrated the feasability of alternative pathways to post‐discharge medication reviews. The HIMRs were conducted sooner than HMRs organised via existing community processes. If post‐discharge medication reviews are organised via the HIMR pathway, there is potential to reduce medication misadventure in high risk patients in a more timely manner than when post‐discharge HMRs are organised.

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Background Clinical pharmacists play an important role in inpatient care; however, their contribution and resultant cost savings are often difficult to define and quantify. Aim To evaluate the use of the pharmacist intervention monitoring (PIM) tool on personnel digital assistants (PDAs) in documenting pharmacy interventions, quantify pharmacy interventions in cost savings, and demonstrate their contribution to inpatient care. Method The study was undertaken on 3 hospital wards over 4 weeks. 2 clinical pharmacists prospectively recorded all interventions, defined as any action that directly resulted in a change to patient management, monitoring or therapy. The interventions likely to affect length‐of‐stay were reviewed by a panel who estimated the likely change in length‐of‐stay, and thus savings in bed‐days and potential cost. Results 179 interventions were documented from a review of 204 drug charts. 22 interventions (12%) prevented major harm, 86 (49%) moderate harm, 65 (36%) minor harm and 6 (3%) were of no clinical significance. 63 interventions were likely to have affected length‐of‐stay, with an estimated 40.3 bed‐days saved, and calculated savings of $13 685. Conclusion This pilot demonstrated the usability of the PIM tool to document clinical interventions by pharmacists on PDA, and provided evidence of the cost‐effectiveness of a clinical pharmacy service.

Background We examined health professionals' views of a novel post‐discharge medication review model for high‐risk patients with 2 referral pathways – general practitioners (GPs) referring for home medicines reviews (HMRs) or hospital doctors referring for hospital‐initiated medication reviews (HIMRs). Aim To identify positive and negative aspects of the model, barriers and facilitators to implementation and to make recommendations for a post‐discharge home medication review program. Method 23 semi‐structured interviews were conducted with key stakeholders – hospital doctors, GPs, accredited pharmacists, hospital pharmacists and community pharmacists. Data were analysed thematically based on a conceptual framework. Results There was consensus that the availability of flexible pathways to post‐discharge home medication reviews was vital for patient care. Participants highlighted it was crucial that the patient's GP and community pharmacist are kept informed if the HIMR pathway was chosen. Barriers to implementation were time constraints experienced by health professionals to organise and conduct the review within 7 days post‐discharge and lack of awareness of the HMR process. Facilitators to implementation included existing positive working relationships and familiarity and support for the HMR process. Suggestions for future implementation included incorporating the liaison pharmacist role into the usual responsibilities of clinical pharmacists and educating medical interns about the model. Conclusion Consensus among medical and pharmacy stakeholders was that streamlined and flexible pathways to post‐discharge medication reviews would enhance quality use of medicines along the continuum of care.