Opinion: hospital pharmacists can support improved transitions into aged care

The latest medicine safety report from the Pharmaceutical Society of Australia (PSA), Medicine Safety: Aged Care, shines a light on problems with the safety and quality of medication management in aged care settings.¹

A key area of concern highlighted in the report is medicine safety during transitions to aged care, which are associated with significant risk of medication errors, missed doses and inappropriate prescribing.¹ The report makes a series of recommendations to improve medicine safety in aged care, including expanding the existing residential medication management review (RMMR) and quality use of medicines (QUM) programs, embedding clinical pharmacists in aged care, remunerating pharmacists for multidisciplinary case conference participation, implementing electronic medication management systems, and improving clinical governance.¹

An important omission from the report is the role of hospital pharmacists in supporting safe transitions to aged care. Medication reconciliation by hospital pharmacists is widely recognised as an important strategy to reduce the risk of discharge prescribing errors.² Interim residential care medication administration charts prepared by hospital pharmacists have been shown to reduce the risk of missed and delayed doses in the immediate post-discharge period,^3,4 and are supported by national aged care medication management guidelines.⁵ Hospital pharmacist involvement in the preparation of medical discharge summaries reduces the risk of medication list errors and improves communication about medication changes and their rationale.^6,7 

The PSA report describes two cases where medication errors occurred during transitions of care from hospital to aged care.¹ In both cases the errors could have been prevented if the aforementioned hospital pharmacist services had been provided. In the case described in Box 6 of the report,¹ where warfarin and other medicines were omitted for several days following discharge from hospital, a hospital pharmacist-prepared interim residential care medication chart could have prevented the errors. In the case described in Box 7,¹ where a prescribing error by the hospital medical practitioner resulted in a serious medication error after discharge, medication reconciliation by a hospital pharmacist prior to discharge could have averted the error. Unfortunately many hospitals lack adequate pharmacist numbers to deliver these evidence-based services consistently. On weekends the delivery of these services is even more limited.

It is unfortunate that the important roles played by hospital pharmacists in supporting transitions of care were not acknowledged in the report, and that no recommendations were made about improving access to evidence-based hospital pharmacist services. The first step towards improving medication safety during transitions of care from hospitals to aged care is to ensure that all patients are reviewed by a hospital pharmacist before discharge, and that all patients receive an interim aged care medication administration chart.^2,5 

Whilst we fully support all of the recommendations made in the report,¹ on their own they will not resolve the problems that occur far too often during transitions of care. The optimal approach to addressing these errors is to prevent them before they happen, at the point of discharge, rather than try to detect and address them after discharge. An adequately funded hospital pharmacy workforce would prevent many of these errors, and we call on the PSA to advocate for this as part of its broader effort to improve medicine safety in aged care.

References

1. Pharmaceutical Society of Australia. Medicine safety: aged care. Canberra. 2020.
2. Duguid M. The importance of medication reconciliation for patients and practitioners. AustPrescr 2012;35:15–19.
3. 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:e000918. doi.org/10.1136/bmjopen-2012-000918
4. Elliott RA, Boutros Y, Tran T, et al. Improving continuity of medication management on discharge to residential care facilities: a 10 year follow-up of the MedGap study. J PharmPract Res 2020 (in press).
5. Department of Health and Ageing. Department of Health and Aged Care. Guiding principles for medication management in residential aged care facilities. Canberra. 2012
6. Tong EY, Roman CP, Mitra B, et al. Reducing medication errors in hospital discharge summaries: a randomised controlled trial. Med J Aust 2017;206:36-39.
7. Elliott RA, Tan Y, Chan V, et al. Pharmacist–Physician Collaboration to Improve the Accuracy of Medication Information in Electronic Medical Discharge Summaries: Effectiveness and Sustainability. Pharmacy 2020;8(1),2. doi.org/10.3390/pharmacy8010002