1. Pharmacist’s Role in Transitions of Care
TuTran Nguyen, PharmD
PGY-2 Internal Medicine Pharmacy Resident
IU Health- Methodist Hospital & Butler University
This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.

2. Medication Discrepancies
Errors
Errors of omission
Errors of commission
Incomplete or inaccurate medication information
Medication Discrepancy: variance in a patient’s documented medication regimen, it can be intentional and clinically relevant adjustment to a patient’s documented medication regimen or it can be unintentional, inaccurate, or incomplete information.
Clev Clin J Gen Intern Med. 2010;25(5):441–7.

3. Question
What percent of in-patient order errors arise from medication histories?
25%
45%
65%
85%

4. Impact of Unintentional Discrepancies
Admission
At least 1 unintended medication discrepancy in 55%
Hospitalization
35.9% of patients experienced medication errors in their hospital orders
Discharge
At least 1 medication error on discharge in 90%
Post-Discharge
66% of adverse events (AEs) were medication related
Inaccurate/incomplete histories may be used to generate regimens for hospitalized patients  ADRs
35.9% of patients experienced errors in their hospital ordered, and 85% of the error originated from the patient’s medication histories.
An adverse event was defined as an injury resulting from medical management rather than the underlying disease  66% found to be medication related (severity ranged from laboratory abnormalities to permanent disability).
62% of medication related AEs were considered preventable
59% of preventable AES were due to miscommunication at discharge between hospital staff with patient and or primary care physician.
This may occur every time a patient is transferred from one level of care to another.
GOAL: to reduce unintentional medication discrepancies
Am J Health-Syst Pharm. 2004;61: Clev Clin J Gen Intern Med. 2010;25(5):441–7. Am J Health-Syst Pharm. 2009;66: Ann Intern Med. 2003;138:

5. Question
During which stages have pharmacist’s intervention(s) resulted in positive impact on patient outcomes?
Admission
During hospitalization
After discharge
i & ii
ii & iii
i & iii
i, ii, & iii

6. Pharmacist’s Role Admission Hospitalization Discharge Post-Discharge
Medication History
21 % discrepancy between pharmacist and physician
Student pharmacists identified significantly more discrepancies
Hospitalization
Reconciliation & Interventions
Decreased preventable adverse drug events
Discharge
Reconciliation & Education
Discharge reconciliation medication errors
Discharge medication discrepancies
Post-Discharge
Follow-up
 Preventable medication related AEs
Medication related readmission/emergency department visit rates
In a prospective evaluation, medication histories obtained by pharmacists and physicians were compared:
-614 medications were identified by the pharmacist, compared with 556 identified by physicians (p ≤ 0.001).
-pharmacist documented significantly more medication doses and dosage schedules than did physicians (614 versus 446 and 614 versus 404, respectively) (p ≤ 0.001)
-27% of patients did not have allergy information documented by the physician
A prospective study evaluating the difference between medication reconciliation performed by student pharmacist vs. RN vs. MDs found that physician and nurses performed similarly to one another in terms of total medications identified during the medication reconciliation process. However, student pharmacists identified significantly more than MD or RN (532 prescription and nonprescription medications compared with 355 identified by nurses and 368 identified by physicians). Student pharmacists also identified significantly more medications per patient (10.2) as compared with nurses (6.8) and physicians (7.1), p=0.006.
80% of discrepancies between student pharmacist list and MD or RN list was non-RX medications.
In a single blinded study, a pharmacist was incorporated into a rounding internal medicine team and compared with an internal medicine team without a pharmacist. The study found that pharmacist interventions and presence as part of a multi-disciplinary team decreased ADEs by 78%
In a prospective study, discharge medication reconciliation was performed and it was found that medication errors on discharge was reduced from 90 to 47% in surgical patients and from 57 to 33% in medicine patients
Prospective study that focused on medication therapy assessment, medication reconciliation, screening for adherence concerns, patient counseling and education, and post discharge telephone follow-up in the intervention group showed a decrease in discharge medication discrepancies from 59% to 33%
Randomized control trial  med rec on discharge, education, and telephone follow up 3-5 days after
Decrease preventable ADEs 1% vs. 11%
The rate of preventable, medication-related ED visits or hospital readmissions within 30 days was 1% in the intervention group and 8% in those assigned to usual care (P = .03).
Interesting note: pharmacists discovered that the medical team had often misunderstood the patient’s preadmission medication regimen and carried through these inaccuracies to the discharge medication orders. Pharmacists also found that 15 patients (16%) admitted to having had problems with their medication regimens before admission, including possible side effects and difficulties with adherence.
Am J Health-Syst Pharm. 2008;65: American Journal of Pharmaceutical Education. 2014;78:(2):Article 34:1-5. Arch Intern Med. 2003;163:
Am J Health-Syst Pharm. 2009;66: Arch Intern Med. 2009;169(21): Arch Intern Med. 2006;166:

7. Question
Which of the following characteristic is considered a risk factor for readmission?
Greater than 5 medications prior to admission
Age >50
Greater than 5 comorbid conditions at admission
Addition of 1 new medication at discharge

8. High Risk Characteristics
Age >70
Admission in previous months (3-6)
Marital status
>3 Comorbid conditions at baseline
Number of treatment specialists involved in patient’s care
Alcohol/substance abuse
Number of medications at discharge
Medications requiring therapeutic monitoring
Two medication therapies started, changed, or stopped during admission
Documented dementia or confusion at baseline
Documented non-adherence
Dependence on feeding tubes
Presence of pressure sores
Arch Intern Med. 2009;169(21): Journal of Hospital Medicine. 2009;4:211–218. Proc (Bayl Univ Med Cent) 2008;21(4):363–372. Q J Med 2011;104:639–651.
JAMA. 2011;306(15): Arch Intern Med. 2012;172(14):

9. Summary
The highest potential for medication errors occur during transitions of care
Pharmacist interventions decrease medication errors and improve patient outcomes
Closer attention should be paid to high risk patients

10. Thank-you! TuTran Nguyen, PharmD