AP
The new Medication Management at Transitions of Care Stewardship Framework highlights the pharmacist’s pivotal role in reducing medicine errors and supporting safe discharge.
Each year, an estimated 250,000 hospital admissions in Australia are caused by medicine-related errors, costing the health system around $1.4 billion annually. More than half of these errors occur during transitions of care.
Recognising the need for immediate action, the Australian Commission on Safety and Quality in Health Care has released the Medication Management at Transitions of Care Stewardship Framework – Australia’s first coordinated hospital-based model designed to reduce medicine errors, improve communication and support safer discharge and follow-up.
For pharmacists in hospitals, general practice, community and aged care, the Framework articulates an opportunity to take a leading role in safeguarding medicines management during the riskiest moments of care.
AP spoke with Dr Phoebe Holdenson Kimura, GP and medical advisor to the Commission, to understand what this means in practice.
National guidance, local implementation
The Framework sets out four interlocking elements to improve safety at transitions of care, the first being the establishment of a governing committee responsible for leadership, oversight and local needs analysis.
‘Many hospitals already do significant work in transitions of care and medication safety, so we anticipate that this governing committee would sit within an existing medication safety or patient safety and quality committee,’ Dr Holdenson Kimura said.
This committee develops the implementation plan, governs risk mitigation activity and evaluates impact. Beneath it sits the second element – a multidisciplinary stewardship team, where pharmacists play a central role.
‘Pharmacists are often the champions of medication safety. We’ve seen their transformative impact through antimicrobial and opioid stewardship models,’ she said.
This team focuses its energy on patients at the highest risk of medicines misadventure, coordinating proactive reviews from admission through to discharge.
The third element outlines specific activities required throughout the patient journey, including early discharge planning and prompt communication with GPs and community pharmacists about medicines changes, while the fourth emphasises ongoing monitoring, evaluation and reporting to ensure hospital systems evolve and improve over time based on real-world performance.
‘This framework aims to raise the bar nationally so that all hospitals take a proactive, systematic approach,’ she said.
Recognising high risk patients
The framework includes a comprehensive list of criteria that can be used to prioritise patients at risk of hospitalisation due to medicines misadventure. This includes patients who are:
- over 65 years of age
- taking five or more medicines or more than 12 doses per day
- using high-risk medicines such as warfarin or insulin
- receiving prescriptions from multiple prescribers
- experiencing major medicine changes within the past 3 months.
‘Many patients admitted to hospital would meet multiple criteria on that list,’ Dr Holdenson Kimura said. ‘So hospitals may choose to pilot the framework with a particular group – for instance, patients over 65 – as part of a staged rollout.’
Once identified, at-risk patients should be flagged for targeted, proactive medicines management.
Safer care from the moment of admission
After flagging at-risk patients, there are several steps for pharmacists to follow on admission, Dr Holdenson Kimura said.
‘First, confirming that the patient’s primary healthcare provider details are correct,’ she said. ‘Sometimes, discharge summaries still go to a GP the patient hasn’t seen in years.’
High-quality medicines reconciliation should ideally occur in the emergency department or soon after admission to the ward.
‘Partnered pharmacist medication charting is also key to preventing errors from the outset,’ Dr Holdenson Kimura added.
Throughout the hospital stay, the Framework emphasises strengthened medicines review and shared decision-making – involving patients in conversations about risks, deprescribing and therapeutic goals.
Preparing for discharge
The Framework strongly promotes early discharge planning, including timely communication with the general practice team – such as the GP, practice nurse or GP pharmacist – to advise them of the admission and any medicines changes, Dr Holdenson Kimura said.
‘This allows the GP to review the patient soon after discharge, reducing the risk of issues or readmission,’ she said.
Hospital pharmacists can also identify at-risk patients who would benefit from a Home Medicines Review (HMR).
‘This can then be communicated directly to the GP or community pharmacy so it happens soon after discharge,’ Dr Holdenson Kimura said.
Community pharmacists also need to be aware of any changes so they can dispense the correct medicines post-discharge.
‘They’re essential because they handle much of the patient education, medication review and reconciliation, and provide continuity of care after discharge,’ she said.
Better communication when systems aren’t interoperable
For many pharmacists, the real challenge lies in communicating effectively across fragmented systems.
‘Digital enablement will be key to realising the full potential of the Framework – but these digital tools need to be interoperable to enable accurate and timely communication,’ Dr Holdenson Kimura said. ‘Ideally, hospital data should integrate smoothly with primary care and community pharmacy software.’
At this stage, the best way to communicate between sectors is through high-quality, accurate and timely digital discharge summaries that reach the right people at the point of discharge.
All information should also be uploaded to My Health Record for continuity of care.
‘For aged care, early communication with the facility – including the registered nurse or on-site pharmacist – ensures medication supply and charts are ready for the patient’s arrival.’
The valuable role of GP and aged care pharmacists
The aged care on-site pharmacist program and successful pilots of pharmacists in general practice suggest that going forward, ‘having pharmacists embedded within general practice or aged care facilities would be a great asset,’ DrHoldenson Kimura said.
Coordination between hospital, GP and pharmacist ensures timely follow-up.
‘If I were a GP working with a GP pharmacist, and we received notice that a patient was being discharged with medication changes, we’d arrange to see that patient within a few days,’ she said.
‘The same principle applies in aged care, where early pharmacist involvement prevents supply gaps and chart discrepancies.’
For patients who are at the highest levels of risk, Dr Holdenson Kimura recommends picking up the phone to contact primary and aged care teams.
‘For urgent, complex, or high-risk patients … the pharmacist should call the GP, registered nurse or on-site pharmacist before discharge to advise them of the patient’s status and any significant medication changes,’ Dr Holdenson Kimura said.
Keen on working in aged care? Enrol in PSA’s Medication Management Review and Aged Care Onsite Pharmacist Credentials.
