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High interruption rates threaten patient safety

Bridging the palliative care education gap for pharmacists

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Case scenario

Amra, 80 years old and a regular patient of yours, has been discharged from hospital after an admission for a fall. She presents at the pharmacy with a bag of medicines and hands you a discharge medicines list. She appears to have been initiated on some new medicines in hospital and expresses confusion on which of her pre-hospital medicines to continue. You view her dispense history and My Health Record and notice discrepancies. It is unclear to you or Amra why some medicines have been initiated. She has an appointment with her GP in a couple of days.

Learning objectives

After reading this article, pharmacists should be able to:

Define transitions of care
Discuss medicines safety during transitions of care
Explain principles of safe and high-quality transitions of care
Discuss the role of the pharmacist across transitions of care.

Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 3.5 Accreditation number: CAP2505SYPMA Accreditation expiry: 31/04/2028

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Medicines safety during transitions of care

The Australian Commission on Safety and Quality in Health Care (ACSQHC) defines transitions of care as the period when all or part of a person’s healthcare is transferred between care providers or care settings.¹

Transitions of care are periods of high risk for medication errors and miscommunication, leading to patient harm. When medicines safety is not prioritised at transitions of care, the risk of adverse events is increased, such as readmission to hospital and adverse drug reactions. A Cochrane review found that more than 50% of patients experience a medication error during transitions of care.² A systematic review found that following hospital discharge to the community, 53% of adult patients experience at least one medication error, 50% experience one or more unintentional medication discrepancies (a subset of medication errors), and 19% experience one or more adverse drug events.³ A systematic review and meta-analysis found the prevalence of medication-related readmissions and adverse drug reaction-related readmissions in older people were 9% and 6%, respectively, with about one-fifth of these preventable.⁴

Preventing medication-related harm at transitions of care is a key priority in the World Health Organization’s (WHO) third Global Patient Safety Challenge (Medication Without Harm).⁵ The ACSQHC’s response to the Challenge, published in 2020, described prioritising medication reconciliation at all transitions of care to reduce the risk of medication errors.⁶ Its response also recommended the use of My Health Record to engage patients and carers in curation and communication of medication regimen information.

The ACSQHC’s response focused on transitions from hospital, a period known to be particularly high risk, and also recommended standardising the presentation of discharge summaries.⁶ For people with complex care needs, initiatives to reduce preventable medication-related readmissions were encouraged, such as early post-discharge medication reviews (hospital outreach or primary care led), and cross-sector case conferencing.⁶ Refinement of risk criteria or indicators was recommended to direct interventions towards patients at the greatest risk of medication-related harm.⁶

The ACSQHC’s response did not specifically address other known contributors to medication-related harm during transitions of care, such as ensuring timely access to medicines and the tools that are sometimes required to use them, such as interim medication administration charts when discharged to residential care, dose administration aids, and adequate quantities of medicines supply.^7,8

Principles of safe and high-quality transitions of care

The ACSQHC has recently published a set of principles to guide safe and high-quality transitions of care that highlight the need for multidisciplinary collaboration and coordination that relies on shared responsibility and accountability.⁹ The consistent application of these principles within practice, standards, policy and guidance are fundamental for safe transitions of care and apply to transitions of care wherever healthcare is received including primary, community, acute, subacute, aged and disability care.⁹

The principles and their enablers are shown in Table 1.

Australia’s priority actions to address medicines safety at transitions of care

Progress toward Australia’s priority actions to address medicines safety at transitions of care has been mixed.¹⁰ Embedding medication reconciliation at admission and discharge from hospital has advanced and is now part of medicines safety standards that hospitals need to meet for accreditation.

My Health Record has improved access to patients’ medication histories; however, patient engagement remains low, and, like all medication records, verification of data with the patient and other sources is required.^11,12 Implementation of the Pharmacist Shared Medicines List (a verified medication history that can be uploaded to My Health Record) has been limited. Discharge summaries continue to have deficiencies, including inaccurate medicine lists and inadequate explanations of medicine changes.¹³ Primary care medicine lists and dose administration aid medicine labels, which are often used by hospital doctors to chart medicines on admission, are also frequently inaccurate.^14,15

Australian research highlights concerns about lack of awareness and uptake of post-discharge Home Medicines Reviews (HMRs) and Residential Medication Management Reviews (RMMRs) and the complexity in facilitating timely post-discharge medication reviews.^16,17 Hospital outreach pharmacist medication review services and cross-sector multidisciplinary case conferencing are uncommon. There has been progress in developing validated criteria to identify patients at risk of medication-related readmission,¹⁸ though more work is needed to ensure generalisability and implementation.¹⁰

Progress towards ensuring timely access to medicines following hospital discharge has been mixed.¹⁰ Reforms to enable medicines to be supplied by hospitals using the Pharmaceutical Benefits Scheme, and implementation of interim medication administration charts for patients discharged to residential care, have not occurred in all jurisdictions.

Drivers for a stewardship approach to improve medicines safety at transitions of care

In 2020, after decades of advocacy, Commonwealth-funded medication review program rules changed to allow hospital-based medical specialists to refer patients to credentialed pharmacists for collaborative post-discharge medication management reviews. In response, the Society of Hospital Pharmacists (now known as Advanced Pharmacy Australia [AdPha]) published a Hospital Pharmacy Practice Update, Hospital-Initiated Medication Reviews, which detailed information about pathways for patients to have post-discharge HMRs, RMMRs and Hospital Outreach Medication Reviews, as well as flagging MedsChecks as a medication reconciliation pathway.¹⁹ Unfortunately, resources were not provided by the Commonwealth or state health departments for promotion, training or implementation support for hospitals to implement hospital-initiated medication reviews, and uptake of these pathways has been low.

An article published in 2022 presented barriers and enablers to hospital-initiated medication reviews, and highlighted the need for a stewardship approach to promote safe and high-quality medication management at transitions of care, with a key focus on facilitating early post-discharge medication reviews (within 10 days).²⁰ The authors have continued to advocate for a hospital-led stewardship approach to address the perennial problem of medicines safety at transitions of care.^10,21

The recently published AdPha Standard of Practice for Pharmacy Services Specialising in Transitions of Care describes current best practice for the provision of pharmacy services that specialise in transitions of care, such as hospital outreach pharmacists and community liaison pharmacists, and supports the introduction of transitions of care stewardship programs into existing organisational clinical systems.²²

Medicines stewardship

Stewardship in the context of health care refers to a structured program of strategies and interventions that address challenges within a specific clinical area, and ensure appropriate and efficient use of resources. Medicines stewardship programs focus on improving medicines use in areas where there is a high risk of inappropriate prescribing or adverse outcomes. Examples of successful programs include: antimicrobial, opioid analgesic, anticoagulation and psychotropic stewardship.²¹

Medicines stewardship programs aim to improve medication management at individual and population levels to ensure consistent, appropriate care. At a population level, this may include developing guidelines and providing standardised processes and templates. At an individual level, it includes delivering tailored person-centred interventions to optimise medication outcomes.

Common elements of successful medicines stewardship programs include multidisciplinary leadership, stakeholder engagement, tailored communication strategies, behavioural changes, implementation science methodologies, and ongoing program monitoring, evaluation and reporting.²¹ Stewardship programs are often led or administered by a dedicated stewardship officer (usually a pharmacist) or team.²¹

Medication Management at Transitions of Care Stewardship Framework

Applying a stewardship approach to transitions of care may provide opportunities to focus organisational resources, foster multi- or interdisciplinary collaboration, and improve coordinated care when individuals transfer between care providers or settings.

In 2023, the ACSQHC commissioned a rapid literature review and environmental scan examining Australian and international medication management strategies, including stewardship programs, at transitions of care focusing on admission to hospital and discharge to the community or residential care.^23,24

The literature review identified that, globally, there are no published studies or existing frameworks that describe a stewardship program specifically addressing medication management at transitions of care.²⁴

Given the evidence from the literature review and environmental scan, the ACSQHC set about developing a Medication Management at Transitions of Care Stewardship Framework (the Framework). The Framework is scheduled for release in the second quarter of 2025.

The Framework is intended to provide healthcare organisations (hospitals) with a systematic approach for implementing coordinated medication management activities and interventions to optimise safe and high-quality transitions of care, with a focus on patients admitted to hospital and discharged to the community or residential aged care. The Framework will provide guidance that can be adapted to local context and the circumstances of individuals transitioning across care settings.

The Framework will be supported by existing national standards and guidelines, including:

National Safety and Quality Health Service Standards²⁵
Guiding Principles to Achieve Continuity in Medication Management⁸
National Medicines Policy 2022.²⁶

The ACSQHC’s principles of safe and high-quality transitions of care⁹ should also be considered in the local implementation of a medication management at transitions of care stewardship program.

Leveraging digital health

Digital health is a key enabler to achieve interoperable, accurate and timely communication between clinicians in the acute and primary care settings. The Framework will align with the National Digital Health Strategy 2023–2028²⁷ and the Strategy Delivery Roadmap.²⁸

Health facilities are encouraged to embed digitally enabled care to strengthen effective interdisciplinary communication and improve safe and high-quality medication management at transitions of care.²⁹

Implementation of the Framework and the role of pharmacists across transitions of care

The Framework is designed with a hospital focus, and it is intended that it will be used by hospitals to guide stewardship and coordination in collaboration with primary care practitioners.²⁹

General practice coordination of ongoing medical care prior to and following hospital discharge is vital, as is community pharmacist coordination of medication supply and management. Pharmacists embedded in general practice, onsite aged care pharmacists, and credentialed pharmacists providing HMRs and RMMRs, can also play an important role. However, it is not possible for general practice and primary care pharmacists to coordinate all time-critical aspects of medication management for complex hospital discharges that occur 7 days a week, and sometimes outside of business hours. In the first instance, hospitals need to take responsibility for bridging the gap by²⁹:

ensuring that discharges are well planned
ensuring there is timely and accurate communication with primary care providers
providing an adequate supply of newly commenced medicines
working with community-based healthcare professionals to ensure continuity of medication access
providing education to patients and carers, including a discharge medicines list
working with community-based healthcare professionals to ensure timely post-discharge medication review and follow-up as needed.

Primary care and aged care pharmacists need to be aware of the risks associated with transitions of care and be prepared to work collaboratively with hospitals in a responsive and flexible way to ensure timely delivery of post-discharge transitions of care-related services such as medication reconciliation, medication supply and medication review.

The authors encourage all pharmacists to engage with the Framework. It is a world-first document that will drive system improvements so Australians receive high-quality care, and is a pivotal response to the WHO’s third Global Patient Safety Challenge (Medication Without Harm) priority, transitions of care.

Case scenario continued

You phone the discharging hospital pharmacist (whose name was recorded on the patient’s discharge medicines list) to clarify Amra’s medicine changes and discharge medication management plan. You speak with Amra about your discussion and obtain consent to complete a MedsCheck and chat with her GP about any changes post-discharge. You go through each of her medicines and prepare her an updated medicines list. You also discuss the potential benefits of a Home Medicines Review (HMR) when there has been a hospital admission and medicine changes. You ask if she wishes for you to discuss an HMR referral with her GP which could be actioned at her upcoming GP appointment. She indicates an HMR would be welcome and thanks you for helping her.

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Key points

A transition of care is when all or part of a person’s healthcare is transferred between care providers or care settings.
Preventing medication-related harm at transitions of care is a key priority in the WHO’s third Global Patient Safety Challenge (Medication Without Harm).
The ACSQHC has developed a Medication Management at Transitions of Care Stewardship Framework to optimise high-quality and safe medication management during transitions of care, focusing on hospital admissions and discharges to community and residential aged care.
Hospital and primary care pharmacists need to work collaboratively to improve the safety of transitions of care and ensure timely post-discharge medication reconciliation, medication supply and post-discharge medication review.

References

Australian Commission on Safety and Quality in Health Care. Transitions of Care. 2024. At: www.safetyandquality.gov.au/our-work/transitions-care
Redmond P, Grimes TC, McDonnell R, et al. Impact of medication reconciliation for improving transitions of care. Cochrane Database of Systematic Reviews 2018, Issue 8.
Alqenae FA, Steinke D, Keers RN. Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. Drug Saf 2020;43(6):517–37.
Prasad N, Lau ECY, Wojt I, et al. Prevalence of and risk factors for drug-related readmissions in older adults: a systematic review and meta-analysis. Drugs Aging 2024;41(1):1–11.
World Health Organization. Medication Without Harm – Global Patient Safety Challenge on Medication Safety. Geneva: World Health Organization; 2017.
Australian Commission on Safety and Quality in Health Care. Medication without harm – WHO Global Patient Safety Challenge. Australia’s response. Sydney: ACSQHC; 2020.
Elliott RA, Tran T, Taylor SE, et al. Impact of a pharmacist-prepared interim residential care medication administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study). BMJ Open 2012;2(3).
Department of Health and Aged Care. Guiding Principles to Achieve Continuity in Medication Management. Canberra; 2022.
Australian Commission on Safety and Quality in Health Care. Principles of safe and high-quality transitions of care (factsheet). 2024.
Elliott RA, Angley M, Criddle DT, et al. Achieving safe medication management during transitions of care from hospital: time for a stewardship approach. Aust Prescr 2024;47(4):106–8.
Elliott RA, Taylor SE, Koo SMK, et al. Accuracy of medication histories derived from an Australian cloud-based repository of prescribed and dispensed medication records. Intern Med J 2023;53:1002–9.
Francis M, Francis P, Makeham M, et al. Using personal health records for medication continuity during transition of care: An observational study. Health Inf Manag 2024:18333583241270215.
Wembridge P, Rashed S. Discharge summary medication list accuracy across five metropolitan hospitals: a retrospective medical record audit. Aust Health Rev 2022;46:338–45.
Uzunbay Z, Elliott RA, Taylor S, et al. Accuracy of medication labels on community pharmacy-prepared dose administration aids: an observational study. Explor Res Clin Soc Pharm 2023;11:100318.
Taylor S, Welch S, Harding A, et al. Accuracy of general practitioner medication histories for patients presenting to the emergency department. Aust Fam Physician 2014;43:728.
Chen EY, Wang KN, Sluggett JK, et al. Process, impact and outcomes of medication review in Australian residential aged care facilities: a systematic review. Australas J Ageing 2019;38:9–25.
Luetsch K, Rowett D, Twigg MJ. A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why? BMJ Qual Saf 2020;30(5):418–30.
Criddle D, Devine B, Murray K, et al. Developing PHarmacie-R: a bedside risk prediction tool with a medicines management focus to identify risk of hospital readmission. Res Social Admin Pharm 2021;18 (7):3137–48.
The Society of Hospital Pharmacists of Australia. Hospital-initiated medication reviews. Collingwood, Victoria: The Society of Hospital Pharmacists of Australia; 2020.
Angley M, Criddle D, Rigby D, et al. Hospital-initiated post-discharge medication reviews in Australia: expert opinion on the barriers and enablers to implementation. J Pharm Pract Res 2022;52(6):446–53.
Su E, Liew DFL, Donnelly J, et al. Medicines stewardship. Aust Prescr 2023;46(2):24–8.
Advanced Pharmacy Australia Transition Care and Primary Care Specialty Practice Group. Standard of practice for pharmacy services specialising in transitions of care. J Pharm Pract Res 2024;54(5):417–35.
Emadi F, Liu S, Yui C H, et al. Digital approaches that can be employed to facilitate safe medication management at transitions of care. Sydney: ACSQHC; 2024.
Emadi F, Liu S, Yiu CH, et al. Medication management at transitions of care stewardship framework. Rapid literature review and environmental scan – final report. Sydney: Faculty of Medicine and Health, School of Pharmacy, University of Sydney; 2023.
Australian Commission on Safety and Quality in Health Care. The National Safety and Quality Health Service (NSQHS) Standards (second edition) 2021. At: www.safetyandquality.gov.au/standards/nsqhs-standards
Department of Health and Aged Care. National Medicines Policy 2022. Canberra; 2022.
Australian Digital Health Agency. National Digital Health Strategy 2023-2028. Sydney; 2023.
Australian Digital Health Agency. National Digital Health Strategy Delivery Roadmap 2023–2028. Sydney; 2023.
Australian Commission on Safety and Quality in Health Care [DRAFT]. Medication Management at Transitions of Care Stewardship Framework. Sydney: ACSQHC; 2024.

Our authors

Manya Angley (she/her) BPharm, PhD, FPS, CredPharm (MMR), FAdPha is an Advanced Practice Pharmacist experienced in general practice, disability and aged care.

Debbie Rigby (she/her) BPharm, GradDipClinPharm, FASCP, FPS, FACP, FAICD, FSHP, FANZCAP (GeriMed, Resp) is an Advanced Practice Pharmacist qualified in clinical pharmacy, geriatrics and respiratory medicine.

Rohan Elliott (he/him) BPharm, BPharmSc(Hons), MClinPharm, PhD, FAdPhA, FANZCAP (GeriMed, Research) is an Advanced Practice Pharmacist with experience in hospitals, aged care and transitions of care.

Our reviewer

Elizabeth Manias (she/her) RN, BPharm, MPharm, MNStud, PhD, FANZCAP (Transitions of care, Geriatric Medicine)

Conflict of interest declaration

Manya Angley, Debbie Rigby and Rohan Elliott are co-investigators on a Medical Research Future Fund (MRFF) 2022 transitions of care project. MRFF is funded by the Australian Government. They are also co-authors of a literature review of transitions of care stewardship that was funded by the ACSQHC.

Elizabeth Manias is a member of the Transitions of Care and Primary Care Leadership Committee of Advanced Pharmacy Australia.

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Improving medicines safety at transitions of care

New CAL medicine storage guidance

Goodbye CAL I, hello expanded CAL 18

Clinical

High interruption rates threaten patient safety

Bridging the palliative care education gap for pharmacists

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