Pharmacist Involvement in Care Transitions in an Academic Medical Center

Abstract

Background: Care transitions pose increased risks for medication errors. Pharmacists are uniquely suited to provide assistance with medication reconciliations and medication counseling during care transitions. Objective:The primary objective of this study was to evaluate the impact of a pharmacist reviewing discharge medication reconciliations and providing medication counseling at the time of hospital discharge.Methods: This retrospective chart review includes adult patients discharged from a range of medicine services from August 23, 2014 to February 7, 2015, at a large academic medical center. The primary outcome was 30-day hospital readmission rate, and secondary outcomes included time-to-hospital readmission, frequency of medication errors, type of medication errors, and frequency of errors per pharmacologic class. Results:In the final analysis, 175 patients were included. The majority of patients in the intervention group had at least one medication error, and the most common error occurred with cardiovascular agents. There was no statistically significant difference between the two groups regarding 30-day hospital readmissions. Conclusion:Although the findings did not show significant differences, a pharmacist was able to identify medication errors in most patients. Additionally, a lack of difference in hospital readmissions is clinically significant, given the intervention group had higher acuity of health care needs.