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palliative care

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            [post_content] => Dedicated palliative care training for pharmacists is not commonplace. This PSA-developed course aims to change that. 

It can be difficult to tell from a prescription that a patient is receiving palliative care, said Tanya Maloney MPS, a community pharmacist in Coffs Harbour, NSW.

[caption id="attachment_29354" align="alignright" width="233"] Tanya Maloney MPS[/caption]

‘What we lack in pharmacy is training on how to approach those difficult conversations in the right way so we can ask them a few questions to determine that,’ she said. ‘We're often a bit nervous about saying the wrong thing.’

Though passionate about palliative care, Ms Maloney and her team have had to learn on the job.

‘We haven’t had any extra training and want to know how we can contribute more.’

This is a common issue through the profession, with a lack in palliative care education tailored specifically to pharmacists, leading to a knowledge gap, said PSA Senior Pharmacist (Consulting and Program Delivery) Megan Tremlett MPS – who has managed a number of palliative care projects through Primary Health Networks and at a state level in recent years.

‘As pharmacists, we don't learn a lot about palliative care in our undergraduate course. And the majority of pharmacists haven't done any extra palliative care education since their university days.’

To address this, PSA launched the ASPIRE Palliative Care Foundation Training Program on 13 May. The free, CPD-accredited course – supported by Palliative Care Australia and funded under the National Palliative Care Grants Program – upskills pharmacists regardless of practice setting.

‘The training program has been created with extensive stakeholder consultation to provide pharmacists with a thorough introduction to palliative care across the eight modules’ Ms Tremlett said.

Rather than training pharmacists to specialise in palliative care, the training program is intended to lift the baseline knowledge of the profession, said Leah Robinson, Project Manager at PSA, who worked on the development of the program with Ms Tremlett.

‘It’s about understanding the different settings and phases of palliative care and at which points pharmacists can provide practical support to help families, patients and healthcare professionals in supporting palliative care.’

A foundational understanding of palliative and end-of-life care across the health workforce is essential to meeting community needs, said Camilla Rowland, CEO of Palliative Care Australia.

‘Supporting people to live, and die well, means building palliative care capability across the entire health system. That includes pharmacists, often among the first healthcare professional patients and carers turn to for advice.’
Learning about symptom management
The ASPIRE training program has a module dedicated to symptoms and the trajectory of people living with life-limiting illness. 

Under a subsequent symptom management module, pharmacists can access resources and references for pharmacological management of the symptoms associated with dying that covers:

 	Pharmaceutical Benefits Scheme (PBS) and non-PBS medicines 
 	Special Access Scheme medications
 	Medicines used off-label.

Experts, from pharmacists to prescribers, guide learners on handling sensitive conversations with patients and families – linking to Safer Care Victoria resources for monitoring and managing adverse effects, especially with continuous subcutaneous infusions.
  
‘We point pharmacists to a range of resources to support them with understanding medicines compatibilities in subcutaneous infusion devices and the adverse effects that might be expected,’ Ms Tremlett said.

As illness progresses, medication regimens often grow more complex.

‘Pharmacists need to be able to step in and make recommendations around those [medicines] that could potentially be weaned or stopped to reduce that burden and the chance of side effects and interactions,’ Ms Tremlett said.

The training program also helps pharmacists with information, tools and resources for conversions of medicines and different formulations, including switching from some or all of their opioids, to a replacement opioid delivered by another route, Ms Robinson said. 

‘It’s also [around] practical things pharmacists can offer such as providing a list of current medicines, home medication review, staged supply, support with prescription management, home delivery or flexibility around dose administration aids to help manage those medicines and the complexity of the changes they go through during the different phases of palliative care,’ Ms Robinson said.
Developing interdisciplinary care skills
At the moment, Ms Maloney feels as though community pharmacy is a missing piece in palliative care that’s uncertain where it fits.

‘We want to be able to fit into that wider team of their health carers so we can look at the holistic care and goals of the person and provide them with more than just medication,’ she said.
  
ASPIRE emphasises collaboration with GPs, specialist palliative care teams, community nurses, paramedics and residential aged care staff.

‘In the module that's dedicated to interdisciplinary palliative care, pharmacists learn the broad range of people who are involved in palliative care, and some they might not expect – from death doulas to chaplains, music therapists and diversional therapists,’ Ms Tremlett said.
Focusing on patient-centred care
Once pharmacists identify a palliative care patient, they need knowledge and skills to determine how best to help at each stage, Ms Maloney said.

‘How do we know how to help them in all these different stages that they're going to go through?’

Pharmacists may think they know what’s best for a patient based on their clinical background, Ms Tremlett said.

‘But at the end of the day, what's important to the person or the patient is the single most important thing.’

‘ASPIRE reminds pharmacists to be mindful of their own biases to meet the person where they are and help them achieve their goals of care, which might change over time as their condition progresses,’ Ms Robinson added.

The patient-centred care module also highlights Australia’s cultural diversity – including First Nations peoples, migrants and those from non-English speaking backgrounds.

‘There is no such thing as a consistent cultural need in palliative care,’ Ms Tremlett said.

‘It's very different within cultures, between cultures and within communities, so pharmacists need to be able to adapt the care and services they provide without making assumptions.’

The need for translation services, what’s deemed an inappropriate conversation or who is the next of kin or carer can vary from person to person, Ms Robinson said.

‘It’s important to be mindful of how and what to communicate to align with those goals of care.’
Helping families through grief and bereavement
Being confident talking about death is something many pharmacists struggle with, Ms Maloney said.

‘You might prompt them a little bit, and they do get upset, and that’s often what puts us off,’ she said. ‘But it’s not necessarily a bad thing as they’re getting to open up and talk to you.’

The final ASPIRE module on grief, bereavement and self-care aims to normalise conversations about death and dying. Being comfortable enough to embed those conversations in day-to-day practice – including supporting people after their loved one has died – is crucial, Ms Tremlett said.

‘It's really important for pharmacists to be prepared to still speak about the person who's died, if that's what the person wants to do, and to recognise that grieving is very normal, and there's no right or wrong way to grieve.’

Pharmacists also need to be able to recognise prolonged grief and know when referrals  for extra support are needed.

‘If the pharmacist has the knowledge and skills to refer that person on for some extra help in the grieving process, that's really impactful,’ she said.

Throughout the palliative care process, it’s crucial for pharmacists to look after themselves and to know when to check in on their colleagues too.

‘When we're constantly supporting people who are unwell … it's very natural for pharmacists to feel a burden of care,’ Ms Tremlett said.

‘Learning to recognise when you or your colleagues might be feeling a little overwhelmed, need extra support or to engage in self-care activities is really important.
Embedding the training into practice
Now that the ASPIRE training program is available, Ms Maloney wants all her pharmacists to complete it to lift their confidence and knowledge in palliative care.

‘As part of that, there's all the resources you can print out and revisit,’ she said.

‘They will be active documents that become part of our internal processes rather than training you just do and forget.’

The experience  of supporting palliative care patients also builds trust and loyalty among family members and carers.

‘You get to know them on a different level and see them when they're vulnerable,’ Ms Maloney said. ‘That rapport you can build up in that time by being there for them definitely builds that lifetime customer for the future.’
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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.

[cpd_submit_answer_button]

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

medicine storage

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            [post_content] => Both Cautionary Advisory Label (CAL) 6 and CAL 13 have been overhauled to sharpen storage advice.

CAL 6 explanatory notes advice in Digital Australian Pharmaceutical Formulary and Handbook (APF) now mentions considerations for room-temperature time windows for refrigerated medicines, while CAL 13’s tightened wording and advice flags truly sensitive formulations – ensuring pharmacists give patients clearer, more precise guidance.
What’s changing?
The familiar ‘Refrigerate, do not freeze’ warning of CAL 6 is not changing, however its explanatory notes have been expanded. 

[caption id="attachment_29335" align="aligncenter" width="180"] CAL 6[/caption]

There are many instances whereby refrigeration of temperature sensitive medicines may not be practical, for example travel days, power outages or ‘in-use’ multi-dose containers/devices. The updated explanatory notes advise pharmacists that they should refer to the medicines approved product information (PI) and counsel their patients on how to best store these medicines – covering when their temperature sensitive medicines may safely remain at room temperature (below 25 °C) – if applicable.

[caption id="attachment_29336" align="aligncenter" width="176"] The old CAL 13[/caption]

[caption id="attachment_29337" align="aligncenter" width="189"] The new CAL 13[/caption]

Meanwhile, CAL 13 has been reworded. Previously ‘Do not remove from original packaging until dose required’, the new prompt, ‘Ask your pharmacist about the storage conditions for this medicine,’ applies only to dosage forms and active ingredients truly sensitive to light, moisture or temperature excursions. 

This includes orally disintegrating tablets, effervescents, sublingual or buccal lozenges, dispersible granules, wafers and chewables, as well as amoxicillin/clavulanic acid, dabigatran, glyceryl trinitrate, nicorandil, nifedipine, phenothiazines, tamoxifen and sodium valproate.

CAL 13 may also be applied in addition to other CALs relating to storage requirements (e.g. CALs 6, 7a or 7b) when complex storage instructions are applicable, and these other CALs do not adequately cover these.

To support the change to CAL 13, the APF’s Good dispensing practice chapter has been updated with clearer and expanded guidance on providing advice to patients on how to store medicines, including that:

 	all medicines should be kept out of sight and out of reach of children at all times
 	unless specifically requiring refrigeration, and in the absence of special storage instructions outlined in the PI/consumer medicine information (CMI), medicines should be stored in their original packaging in a cool (preferably <25 °C), dry and secure place
 	medicines should generally not be removed from their original packaging until a dose is required – pharmacists should check how the patient intends to store their medicines (e.g. in a dosette box) and provide advice according to the storage instructions outlined in each medicines PI/CMI.

CAL 13’s explanatory notes have also been updated in APF Digital to support pharmacists in applying the revised CAL.

When packing medicines into Dose Administration Aids (DAAs) pharmacists should consider the approved PI of each medicine, and PSA’s Guidelines for pharmacists providing dose administration aid services.
What led to this update?
Medicine labels have traditionally relied on simple fridge-or-no-fridge advice. But today’s PIs are more complex. 

Humira (adalimumab) is one good example. People using Humira are advised that they can store single pre-filled syringes or pens ‘below 25°C (room temperature) for a maximum period of 14 days, but must be protected from light. Once removed from the refrigerator for room temperature storage, the syringe must be used within 14 days or discarded, even if it is returned to the refrigerator’. 

But CAL 6 doesn’t capture these nuances, so some patients are left guessing whether their medicines are safe to use or not during travel or at times when refrigeration is not available. The new explanatory notes prompt pharmacists to cover these scenarios as part of their routine counselling to promote safe and quality use of medicines.

At the same time, the CAL 13 had become so ubiquitous – applicable to nearly all medicines – that its impact was diluted. What's more, most pharmacies didn’t even stock the printed sticker. 

By narrowing its application, CAL 13’s power to prompt meaningful conversations about stability risks has been restored.

Above all, when medicines are removed from their original packaging inappropriately, or stored incorrectly, this can translate into reduced potency or patient harm. These refinements give pharmacists clear, evidence-based cues to maintain medicine stability and efficacy. 
How should pharmacists tailor storage advice?
Pharmacists should personalise both verbal and written advice to the patient. Ensure every patient is counselled on how to best store their medicines including routinely asking how the patient plans to keep their medicines, for example will they use a dosette box? Is storage at an appropriate temperature an issue?

If a medicine carries Label 6 but its PI indicates there is an appropriate room-temperature window, demonstrate the correct use of an insulated bag and explain the difference between ‘keep at 2–8 °C’ and ‘store below 25 °C’. Provide guidance on room temperature storage for their in-use multi dose container/device (if appropriate) and for times when refrigeration is unavailable or impractical.

Pharmacists should also advise the patient to avoid storing medicines in the areas of a domestic refrigerator that may not maintain a temperature of 2–8 °C. This includes the door, top shelf or crisper; or within 40 mm of the back and sides of the main compartment.

For CAL-13 affixed medicines, pharmacists should advise patients that these medications’ stability is protected by the original container and packaging, and that removing them prematurely can accelerate degradation and reduce efficacy. Work with the patient to address any barriers to this.
What’s the implementation timeline?
The revised explanatory notes for CAL 6 and CAL 13 are live in APF Digital as of 7 May 2025. 

CAL printers will begin issuing the new CAL 13 labels on their next run. Until then, pharmacists should continue using the existing labels while equipping patients with the updated counselling points and advice outlined in the APF Digital.
How should pharmacists put the new advice into practice?
Let’s say Mrs L, 68, who has type 2 diabetes, atrial fibrillation and hypertension, presents to a pharmacy for her medicines. She picks up a prescription for insulin glargine pens, nifedipine and dabigatran. For her insulin glargine, you apply Label 6 and explain the medicine must be stored at 2–8 °C in the fridge’s main compartment, yet the in-use pen may remain at room temperature for up to 28 days. You provide her with an insulated bag and demonstrate how to use it.

You then recognise that nifedipine is sensitive to light and dabigatran is moisture-sensitive, and apply Label 13 to each medicine’s packaging which prompts a PI check. You advise her to keep the medicines away from humid spots such as bathrooms or kitchen windowsills, and to keep them in their original packaging, out of direct light. Mrs L leaves confident in where to store each medicine, and you’ve pre-emptively safeguarded stability and efficacy.
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New CAL medicine storage guidance

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            [post_content] => Merging CAL 18 and CAL I removes duplication and confusion, helping patients receive clearer, more actionable dietary advice.

Australian Pharmacist explores what pharmacists and patients need to know.

What’s changing?

Cautionary advisory label (CAL) 18 and CAL I currently provide dietary advice for specific medicines:

[caption id="attachment_29312" align="aligncenter" width="151"] CAL 18[/caption]

[caption id="attachment_29311" align="aligncenter" width="152"] CAL I[/caption]
Instead of having two labels that relate to avoiding certain foods and juices (CAL 18 and CAL I), there will now be one – an updated CAL 18.


[caption id="attachment_29313" align="aligncenter" width="189"] Revised CAL 18[/caption]
What’s the rationale?
Currently, CAL 18 only warns about grapefruit due to its effect on the bioavailability of certain medicines through the selective inhibition of cytochrome P450 3A4 isoenzymes. But the product information (PI) for new medicines that are substrates for CYP3A4 increasingly mention other fruits (beyond just grapefruit) as interacting with medicines via inhibition of CYP3A4. This includes seville oranges, pomelo, star fruit, bitter melon and pomegranate. 

As it stands, the wording of CAL 18 is not broad enough to cover these scenarios.

CAL I is currently used to advise patients about fruits and juices that interact with medicines through mechanisms other than inhibition of CYP3A4. 

For example, food and drink interactions with non-selective monoamine oxidase inhibitors (MAOIs) and interactions between medicines and fruit juices through mechanisms other than CYP3A4 inhibition (e.g. fexofenadine, which has been found to interact with orange and apple juice). 

However, there have been reports of confusion associated with ‘I’ appearing very similar to ‘1’ in the CAL recommendation table. There are also not many medicines CAL I is relevant to at present, so it therefore has limited applicability. 

The revised CAL 18, now reading ‘Certain foods and fruit juices should be avoided while being treated with this medicine’, will now cover:

 	interactions with all CYP3A4-inhibiting fruits (for example, grapefruit, Seville orange, pomelo, pomegranate, star fruit) 
 	any newly identified food and juice interactions with medicines – even those that don’t occur by CYP3A4 (e.g. apple and orange juice); and
 	other food and drink interactions with medicines (e.g. foods and drinks rich in tyramine with MAOIs).

How should pharmacists respond when patients ask which foods and fruit juices should be avoided?
For those fruits that can inhibit CYP3A4 (e.g. grapefruit, Seville orange, pomelo, star fruit, bitter melon and pomegranate), this can lead to higher drug levels and potential toxicity of relevant CYP3A4 substrates. Pharmacists should advise patients that these fruits should be avoided in any form (e.g. fruit or juice) with these medicines as there is no recommendation on the quantity that can be safely consumed.

Beyond CYP3A4 substrates, it becomes more nuanced. For example, atenolol and fexofenadine aren’t metabolised by CYP3A4, yet both can have reduced bioavailability when taken with apple or orange juice – so patients taking these medicines should be advised to avoid these juices.

When dispensing MAOIs, pharmacists should counsel patients to avoid tyramine-rich foods such as aged cheeses, cured meats, fermented products, yeast extract products and beer. Other certain foods and drinks must be consumed only in small amounts. MAOIs block the enzyme that normally breaks down tyramine, causing it to accumulate in the bloodstream, which can lead to a hypertensive crisis. Pharmacists should provide an MAOI card to patients, see APF Digital – Counselling advice for monoamine oxidase inhibitors. 

It is important that pharmacists check a medicines’ approved PI to confirm the specific foods, fruits and juices that patients should avoid. Appropriate drug interaction resources (e.g. Stockley’s Drug Interactions) should also be used where needed when providing medicine-specific advice.
When is the change happening?
The CAL explanatory notes were updated in APF Digital today (7 May 2025).

Pharmacists should familiarise themselves with the revised explanatory notes for CAL 18 in the digital Australian Pharmaceutical Formulary and Handbook.
When will dispensing software be updated with the revised CALs?
Pharmacists are advised to talk to their dispensing software provider, who can advise when these changes will be implemented.
When will the new labels arrive?
It is anticipated printers will commence printing of the new labels during their next print run.

Until then, pharmacists should use the existing CAL 18 and CAL I – ensuring patients are equipped with the updated advice, available now in APF Digital which always contains the latest updates.
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Goodbye CAL I, hello expanded CAL 18

measles

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            [post_content] => With measles cases climbing across Australia and pharmacies increasingly listed as exposure sites, community pharmacists must be prepared.


Earlier this year, a patient who had just returned from Vietnam walked into Advantage Chesterville Pharmacy in Melbourne with a script for antibiotics.

‘She was wearing a face mask, and when I spoke to her she just said that she had a cough but she wasn't sure what the cough was from,’ said community pharmacist Minh Ngo MPS, who was on duty when the patient came through.

Some time later, the pharmacy received word that the patient was infected with measles.

‘She either informed the hospital or the GP, but we just got a call from the [Victorian] Department of Health to notify us that we were an exposure case,’ she said.

With measles spreading around Australia at an unprecedented rate, this is a position many pharmacists may soon find themselves in.

Victoria is in the midst of its worst measles outbreak in a decade, with 25 cases recorded so far this year. New South Wales and Western Australia are not far behind, with 21 and 18 cases reported respectively.

Healthcare settings such as pharmacies have been increasingly listed as exposure sites as people seek treatment for the highly infectious and virulent disease.

Australian Pharmacist explores the steps pharmacists should take when confronted with this predicament.
Patient contact tracing
When a healthcare setting such as a pharmacy becomes a measles exposure site, it is responsible for contact tracing.

‘We had to inform every patient who was in the [pharmacy] at that time that we were informed that the exposure might have happened,’ Ms Ngo said. 

This includes asking patients if they have any symptoms. Early symptoms of measles, before the rash appears, include:

 	fever 
 	tiredness 
 	cough 
 	runny nose
 	sore red eyes 
 	malaise.

‘We had to inform every patient who was in the [pharmacy] at that time that we were informed that the exposure might have happened.'

MINH NGO MPS  
Post-exposure testing and prophylaxis
All symptomatic patients who were exposed to measles need to follow specific protocols. 

‘We told them that if they have any symptoms, if they develop any cough or if they have any concerns then go and get tested,’ Ms Ngo said. 

Patients who have attended a known exposure site should be offered the Measles, Mumps, and Rubella vaccine within 72 hours of measles exposure to avert infection. In those who are unvaccinated or partially vaccinated, particularly young infants, pregnant people,, or immunocompromised patients – human immunoglobulin (NHIG) administered within six days of exposure may be appropriate.

Pharmacists should advise patients with suspected measles to call ahead before visiting their healthcare provider for a PCR test and wear a mask upon leaving home. Suspected cases must remain isolated at home until laboratory testing confirms or excludes measles, avoiding work, school and any public venues.

A notification must be made to the relevant department of health when symptoms are present via the patients' local public health unit.
Important staff protocols
Fortunately, there were only two members of staff on at the pharmacy including Ms Ngo at the time of the exposure, and neither was infected with measles.

Local PHUs will identify any staff who may have been exposed to a measles case and assess their immunity status, said a spokesperson from the federal Department of Health and Aged Care. 

‘Depending on their vaccination history, some staff members may need to be monitored or excluded from work during the infectious period to minimise the risk of further transmission – this could be for a period up to 18 days,’ the spokesperson said. ‘Post-exposure prophylaxis may be required and will be organised by the local PHU.’

With the number of cases currently floating around, pharmacists should ensure that staff are up to date with their vaccinations in advance

All adults born between 1966 and 1992 and who do not have documented evidence of vaccination are eligible for a catch-up vaccine to ensure maximum protection against measles, with the two-dose schedule of the MMR vaccine only being introduced in Australia in 1992.

https://twitter.com/VicGovDH/status/1916756251293409486

Should a patient present with a fever and rash, they should be moved out of communal waiting areas and into a dedicated space. If measles is suspected, the patient should be given a disposable, well-sealed mask.
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Responding to a measles exposure in your pharmacy

palliative care

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            [post_content] => Dedicated palliative care training for pharmacists is not commonplace. This PSA-developed course aims to change that. 

It can be difficult to tell from a prescription that a patient is receiving palliative care, said Tanya Maloney MPS, a community pharmacist in Coffs Harbour, NSW.

[caption id="attachment_29354" align="alignright" width="233"] Tanya Maloney MPS[/caption]

‘What we lack in pharmacy is training on how to approach those difficult conversations in the right way so we can ask them a few questions to determine that,’ she said. ‘We're often a bit nervous about saying the wrong thing.’

Though passionate about palliative care, Ms Maloney and her team have had to learn on the job.

‘We haven’t had any extra training and want to know how we can contribute more.’

This is a common issue through the profession, with a lack in palliative care education tailored specifically to pharmacists, leading to a knowledge gap, said PSA Senior Pharmacist (Consulting and Program Delivery) Megan Tremlett MPS – who has managed a number of palliative care projects through Primary Health Networks and at a state level in recent years.

‘As pharmacists, we don't learn a lot about palliative care in our undergraduate course. And the majority of pharmacists haven't done any extra palliative care education since their university days.’

To address this, PSA launched the ASPIRE Palliative Care Foundation Training Program on 13 May. The free, CPD-accredited course – supported by Palliative Care Australia and funded under the National Palliative Care Grants Program – upskills pharmacists regardless of practice setting.

‘The training program has been created with extensive stakeholder consultation to provide pharmacists with a thorough introduction to palliative care across the eight modules’ Ms Tremlett said.

Rather than training pharmacists to specialise in palliative care, the training program is intended to lift the baseline knowledge of the profession, said Leah Robinson, Project Manager at PSA, who worked on the development of the program with Ms Tremlett.

‘It’s about understanding the different settings and phases of palliative care and at which points pharmacists can provide practical support to help families, patients and healthcare professionals in supporting palliative care.’

A foundational understanding of palliative and end-of-life care across the health workforce is essential to meeting community needs, said Camilla Rowland, CEO of Palliative Care Australia.

‘Supporting people to live, and die well, means building palliative care capability across the entire health system. That includes pharmacists, often among the first healthcare professional patients and carers turn to for advice.’
Learning about symptom management
The ASPIRE training program has a module dedicated to symptoms and the trajectory of people living with life-limiting illness. 

Under a subsequent symptom management module, pharmacists can access resources and references for pharmacological management of the symptoms associated with dying that covers:

 	Pharmaceutical Benefits Scheme (PBS) and non-PBS medicines 
 	Special Access Scheme medications
 	Medicines used off-label.

Experts, from pharmacists to prescribers, guide learners on handling sensitive conversations with patients and families – linking to Safer Care Victoria resources for monitoring and managing adverse effects, especially with continuous subcutaneous infusions.
  
‘We point pharmacists to a range of resources to support them with understanding medicines compatibilities in subcutaneous infusion devices and the adverse effects that might be expected,’ Ms Tremlett said.

As illness progresses, medication regimens often grow more complex.

‘Pharmacists need to be able to step in and make recommendations around those [medicines] that could potentially be weaned or stopped to reduce that burden and the chance of side effects and interactions,’ Ms Tremlett said.

The training program also helps pharmacists with information, tools and resources for conversions of medicines and different formulations, including switching from some or all of their opioids, to a replacement opioid delivered by another route, Ms Robinson said. 

‘It’s also [around] practical things pharmacists can offer such as providing a list of current medicines, home medication review, staged supply, support with prescription management, home delivery or flexibility around dose administration aids to help manage those medicines and the complexity of the changes they go through during the different phases of palliative care,’ Ms Robinson said.
Developing interdisciplinary care skills
At the moment, Ms Maloney feels as though community pharmacy is a missing piece in palliative care that’s uncertain where it fits.

‘We want to be able to fit into that wider team of their health carers so we can look at the holistic care and goals of the person and provide them with more than just medication,’ she said.
  
ASPIRE emphasises collaboration with GPs, specialist palliative care teams, community nurses, paramedics and residential aged care staff.

‘In the module that's dedicated to interdisciplinary palliative care, pharmacists learn the broad range of people who are involved in palliative care, and some they might not expect – from death doulas to chaplains, music therapists and diversional therapists,’ Ms Tremlett said.
Focusing on patient-centred care
Once pharmacists identify a palliative care patient, they need knowledge and skills to determine how best to help at each stage, Ms Maloney said.

‘How do we know how to help them in all these different stages that they're going to go through?’

Pharmacists may think they know what’s best for a patient based on their clinical background, Ms Tremlett said.

‘But at the end of the day, what's important to the person or the patient is the single most important thing.’

‘ASPIRE reminds pharmacists to be mindful of their own biases to meet the person where they are and help them achieve their goals of care, which might change over time as their condition progresses,’ Ms Robinson added.

The patient-centred care module also highlights Australia’s cultural diversity – including First Nations peoples, migrants and those from non-English speaking backgrounds.

‘There is no such thing as a consistent cultural need in palliative care,’ Ms Tremlett said.

‘It's very different within cultures, between cultures and within communities, so pharmacists need to be able to adapt the care and services they provide without making assumptions.’

The need for translation services, what’s deemed an inappropriate conversation or who is the next of kin or carer can vary from person to person, Ms Robinson said.

‘It’s important to be mindful of how and what to communicate to align with those goals of care.’
Helping families through grief and bereavement
Being confident talking about death is something many pharmacists struggle with, Ms Maloney said.

‘You might prompt them a little bit, and they do get upset, and that’s often what puts us off,’ she said. ‘But it’s not necessarily a bad thing as they’re getting to open up and talk to you.’

The final ASPIRE module on grief, bereavement and self-care aims to normalise conversations about death and dying. Being comfortable enough to embed those conversations in day-to-day practice – including supporting people after their loved one has died – is crucial, Ms Tremlett said.

‘It's really important for pharmacists to be prepared to still speak about the person who's died, if that's what the person wants to do, and to recognise that grieving is very normal, and there's no right or wrong way to grieve.’

Pharmacists also need to be able to recognise prolonged grief and know when referrals  for extra support are needed.

‘If the pharmacist has the knowledge and skills to refer that person on for some extra help in the grieving process, that's really impactful,’ she said.

Throughout the palliative care process, it’s crucial for pharmacists to look after themselves and to know when to check in on their colleagues too.

‘When we're constantly supporting people who are unwell … it's very natural for pharmacists to feel a burden of care,’ Ms Tremlett said.

‘Learning to recognise when you or your colleagues might be feeling a little overwhelmed, need extra support or to engage in self-care activities is really important.
Embedding the training into practice
Now that the ASPIRE training program is available, Ms Maloney wants all her pharmacists to complete it to lift their confidence and knowledge in palliative care.

‘As part of that, there's all the resources you can print out and revisit,’ she said.

‘They will be active documents that become part of our internal processes rather than training you just do and forget.’

The experience  of supporting palliative care patients also builds trust and loyalty among family members and carers.

‘You get to know them on a different level and see them when they're vulnerable,’ Ms Maloney said. ‘That rapport you can build up in that time by being there for them definitely builds that lifetime customer for the future.’
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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

medicine storage

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            [post_content] => Both Cautionary Advisory Label (CAL) 6 and CAL 13 have been overhauled to sharpen storage advice.

CAL 6 explanatory notes advice in Digital Australian Pharmaceutical Formulary and Handbook (APF) now mentions considerations for room-temperature time windows for refrigerated medicines, while CAL 13’s tightened wording and advice flags truly sensitive formulations – ensuring pharmacists give patients clearer, more precise guidance.
What’s changing?
The familiar ‘Refrigerate, do not freeze’ warning of CAL 6 is not changing, however its explanatory notes have been expanded. 

[caption id="attachment_29335" align="aligncenter" width="180"] CAL 6[/caption]

There are many instances whereby refrigeration of temperature sensitive medicines may not be practical, for example travel days, power outages or ‘in-use’ multi-dose containers/devices. The updated explanatory notes advise pharmacists that they should refer to the medicines approved product information (PI) and counsel their patients on how to best store these medicines – covering when their temperature sensitive medicines may safely remain at room temperature (below 25 °C) – if applicable.

[caption id="attachment_29336" align="aligncenter" width="176"] The old CAL 13[/caption]

[caption id="attachment_29337" align="aligncenter" width="189"] The new CAL 13[/caption]

Meanwhile, CAL 13 has been reworded. Previously ‘Do not remove from original packaging until dose required’, the new prompt, ‘Ask your pharmacist about the storage conditions for this medicine,’ applies only to dosage forms and active ingredients truly sensitive to light, moisture or temperature excursions. 

This includes orally disintegrating tablets, effervescents, sublingual or buccal lozenges, dispersible granules, wafers and chewables, as well as amoxicillin/clavulanic acid, dabigatran, glyceryl trinitrate, nicorandil, nifedipine, phenothiazines, tamoxifen and sodium valproate.

CAL 13 may also be applied in addition to other CALs relating to storage requirements (e.g. CALs 6, 7a or 7b) when complex storage instructions are applicable, and these other CALs do not adequately cover these.

To support the change to CAL 13, the APF’s Good dispensing practice chapter has been updated with clearer and expanded guidance on providing advice to patients on how to store medicines, including that:

 	all medicines should be kept out of sight and out of reach of children at all times
 	unless specifically requiring refrigeration, and in the absence of special storage instructions outlined in the PI/consumer medicine information (CMI), medicines should be stored in their original packaging in a cool (preferably <25 °C), dry and secure place
 	medicines should generally not be removed from their original packaging until a dose is required – pharmacists should check how the patient intends to store their medicines (e.g. in a dosette box) and provide advice according to the storage instructions outlined in each medicines PI/CMI.

CAL 13’s explanatory notes have also been updated in APF Digital to support pharmacists in applying the revised CAL.

When packing medicines into Dose Administration Aids (DAAs) pharmacists should consider the approved PI of each medicine, and PSA’s Guidelines for pharmacists providing dose administration aid services.
What led to this update?
Medicine labels have traditionally relied on simple fridge-or-no-fridge advice. But today’s PIs are more complex. 

Humira (adalimumab) is one good example. People using Humira are advised that they can store single pre-filled syringes or pens ‘below 25°C (room temperature) for a maximum period of 14 days, but must be protected from light. Once removed from the refrigerator for room temperature storage, the syringe must be used within 14 days or discarded, even if it is returned to the refrigerator’. 

But CAL 6 doesn’t capture these nuances, so some patients are left guessing whether their medicines are safe to use or not during travel or at times when refrigeration is not available. The new explanatory notes prompt pharmacists to cover these scenarios as part of their routine counselling to promote safe and quality use of medicines.

At the same time, the CAL 13 had become so ubiquitous – applicable to nearly all medicines – that its impact was diluted. What's more, most pharmacies didn’t even stock the printed sticker. 

By narrowing its application, CAL 13’s power to prompt meaningful conversations about stability risks has been restored.

Above all, when medicines are removed from their original packaging inappropriately, or stored incorrectly, this can translate into reduced potency or patient harm. These refinements give pharmacists clear, evidence-based cues to maintain medicine stability and efficacy. 
How should pharmacists tailor storage advice?
Pharmacists should personalise both verbal and written advice to the patient. Ensure every patient is counselled on how to best store their medicines including routinely asking how the patient plans to keep their medicines, for example will they use a dosette box? Is storage at an appropriate temperature an issue?

If a medicine carries Label 6 but its PI indicates there is an appropriate room-temperature window, demonstrate the correct use of an insulated bag and explain the difference between ‘keep at 2–8 °C’ and ‘store below 25 °C’. Provide guidance on room temperature storage for their in-use multi dose container/device (if appropriate) and for times when refrigeration is unavailable or impractical.

Pharmacists should also advise the patient to avoid storing medicines in the areas of a domestic refrigerator that may not maintain a temperature of 2–8 °C. This includes the door, top shelf or crisper; or within 40 mm of the back and sides of the main compartment.

For CAL-13 affixed medicines, pharmacists should advise patients that these medications’ stability is protected by the original container and packaging, and that removing them prematurely can accelerate degradation and reduce efficacy. Work with the patient to address any barriers to this.
What’s the implementation timeline?
The revised explanatory notes for CAL 6 and CAL 13 are live in APF Digital as of 7 May 2025. 

CAL printers will begin issuing the new CAL 13 labels on their next run. Until then, pharmacists should continue using the existing labels while equipping patients with the updated counselling points and advice outlined in the APF Digital.
How should pharmacists put the new advice into practice?
Let’s say Mrs L, 68, who has type 2 diabetes, atrial fibrillation and hypertension, presents to a pharmacy for her medicines. She picks up a prescription for insulin glargine pens, nifedipine and dabigatran. For her insulin glargine, you apply Label 6 and explain the medicine must be stored at 2–8 °C in the fridge’s main compartment, yet the in-use pen may remain at room temperature for up to 28 days. You provide her with an insulated bag and demonstrate how to use it.

You then recognise that nifedipine is sensitive to light and dabigatran is moisture-sensitive, and apply Label 13 to each medicine’s packaging which prompts a PI check. You advise her to keep the medicines away from humid spots such as bathrooms or kitchen windowsills, and to keep them in their original packaging, out of direct light. Mrs L leaves confident in where to store each medicine, and you’ve pre-emptively safeguarded stability and efficacy.
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New CAL medicine storage guidance

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            [post_content] => Merging CAL 18 and CAL I removes duplication and confusion, helping patients receive clearer, more actionable dietary advice.

Australian Pharmacist explores what pharmacists and patients need to know.

What’s changing?

Cautionary advisory label (CAL) 18 and CAL I currently provide dietary advice for specific medicines:

[caption id="attachment_29312" align="aligncenter" width="151"] CAL 18[/caption]

[caption id="attachment_29311" align="aligncenter" width="152"] CAL I[/caption]
Instead of having two labels that relate to avoiding certain foods and juices (CAL 18 and CAL I), there will now be one – an updated CAL 18.


[caption id="attachment_29313" align="aligncenter" width="189"] Revised CAL 18[/caption]
What’s the rationale?
Currently, CAL 18 only warns about grapefruit due to its effect on the bioavailability of certain medicines through the selective inhibition of cytochrome P450 3A4 isoenzymes. But the product information (PI) for new medicines that are substrates for CYP3A4 increasingly mention other fruits (beyond just grapefruit) as interacting with medicines via inhibition of CYP3A4. This includes seville oranges, pomelo, star fruit, bitter melon and pomegranate. 

As it stands, the wording of CAL 18 is not broad enough to cover these scenarios.

CAL I is currently used to advise patients about fruits and juices that interact with medicines through mechanisms other than inhibition of CYP3A4. 

For example, food and drink interactions with non-selective monoamine oxidase inhibitors (MAOIs) and interactions between medicines and fruit juices through mechanisms other than CYP3A4 inhibition (e.g. fexofenadine, which has been found to interact with orange and apple juice). 

However, there have been reports of confusion associated with ‘I’ appearing very similar to ‘1’ in the CAL recommendation table. There are also not many medicines CAL I is relevant to at present, so it therefore has limited applicability. 

The revised CAL 18, now reading ‘Certain foods and fruit juices should be avoided while being treated with this medicine’, will now cover:

 	interactions with all CYP3A4-inhibiting fruits (for example, grapefruit, Seville orange, pomelo, pomegranate, star fruit) 
 	any newly identified food and juice interactions with medicines – even those that don’t occur by CYP3A4 (e.g. apple and orange juice); and
 	other food and drink interactions with medicines (e.g. foods and drinks rich in tyramine with MAOIs).

How should pharmacists respond when patients ask which foods and fruit juices should be avoided?
For those fruits that can inhibit CYP3A4 (e.g. grapefruit, Seville orange, pomelo, star fruit, bitter melon and pomegranate), this can lead to higher drug levels and potential toxicity of relevant CYP3A4 substrates. Pharmacists should advise patients that these fruits should be avoided in any form (e.g. fruit or juice) with these medicines as there is no recommendation on the quantity that can be safely consumed.

Beyond CYP3A4 substrates, it becomes more nuanced. For example, atenolol and fexofenadine aren’t metabolised by CYP3A4, yet both can have reduced bioavailability when taken with apple or orange juice – so patients taking these medicines should be advised to avoid these juices.

When dispensing MAOIs, pharmacists should counsel patients to avoid tyramine-rich foods such as aged cheeses, cured meats, fermented products, yeast extract products and beer. Other certain foods and drinks must be consumed only in small amounts. MAOIs block the enzyme that normally breaks down tyramine, causing it to accumulate in the bloodstream, which can lead to a hypertensive crisis. Pharmacists should provide an MAOI card to patients, see APF Digital – Counselling advice for monoamine oxidase inhibitors. 

It is important that pharmacists check a medicines’ approved PI to confirm the specific foods, fruits and juices that patients should avoid. Appropriate drug interaction resources (e.g. Stockley’s Drug Interactions) should also be used where needed when providing medicine-specific advice.
When is the change happening?
The CAL explanatory notes were updated in APF Digital today (7 May 2025).

Pharmacists should familiarise themselves with the revised explanatory notes for CAL 18 in the digital Australian Pharmaceutical Formulary and Handbook.
When will dispensing software be updated with the revised CALs?
Pharmacists are advised to talk to their dispensing software provider, who can advise when these changes will be implemented.
When will the new labels arrive?
It is anticipated printers will commence printing of the new labels during their next print run.

Until then, pharmacists should use the existing CAL 18 and CAL I – ensuring patients are equipped with the updated advice, available now in APF Digital which always contains the latest updates.
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Goodbye CAL I, hello expanded CAL 18

measles

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            [post_content] => With measles cases climbing across Australia and pharmacies increasingly listed as exposure sites, community pharmacists must be prepared.


Earlier this year, a patient who had just returned from Vietnam walked into Advantage Chesterville Pharmacy in Melbourne with a script for antibiotics.

‘She was wearing a face mask, and when I spoke to her she just said that she had a cough but she wasn't sure what the cough was from,’ said community pharmacist Minh Ngo MPS, who was on duty when the patient came through.

Some time later, the pharmacy received word that the patient was infected with measles.

‘She either informed the hospital or the GP, but we just got a call from the [Victorian] Department of Health to notify us that we were an exposure case,’ she said.

With measles spreading around Australia at an unprecedented rate, this is a position many pharmacists may soon find themselves in.

Victoria is in the midst of its worst measles outbreak in a decade, with 25 cases recorded so far this year. New South Wales and Western Australia are not far behind, with 21 and 18 cases reported respectively.

Healthcare settings such as pharmacies have been increasingly listed as exposure sites as people seek treatment for the highly infectious and virulent disease.

Australian Pharmacist explores the steps pharmacists should take when confronted with this predicament.
Patient contact tracing
When a healthcare setting such as a pharmacy becomes a measles exposure site, it is responsible for contact tracing.

‘We had to inform every patient who was in the [pharmacy] at that time that we were informed that the exposure might have happened,’ Ms Ngo said. 

This includes asking patients if they have any symptoms. Early symptoms of measles, before the rash appears, include:

 	fever 
 	tiredness 
 	cough 
 	runny nose
 	sore red eyes 
 	malaise.

‘We had to inform every patient who was in the [pharmacy] at that time that we were informed that the exposure might have happened.'

MINH NGO MPS  
Post-exposure testing and prophylaxis
All symptomatic patients who were exposed to measles need to follow specific protocols. 

‘We told them that if they have any symptoms, if they develop any cough or if they have any concerns then go and get tested,’ Ms Ngo said. 

Patients who have attended a known exposure site should be offered the Measles, Mumps, and Rubella vaccine within 72 hours of measles exposure to avert infection. In those who are unvaccinated or partially vaccinated, particularly young infants, pregnant people,, or immunocompromised patients – human immunoglobulin (NHIG) administered within six days of exposure may be appropriate.

Pharmacists should advise patients with suspected measles to call ahead before visiting their healthcare provider for a PCR test and wear a mask upon leaving home. Suspected cases must remain isolated at home until laboratory testing confirms or excludes measles, avoiding work, school and any public venues.

A notification must be made to the relevant department of health when symptoms are present via the patients' local public health unit.
Important staff protocols
Fortunately, there were only two members of staff on at the pharmacy including Ms Ngo at the time of the exposure, and neither was infected with measles.

Local PHUs will identify any staff who may have been exposed to a measles case and assess their immunity status, said a spokesperson from the federal Department of Health and Aged Care. 

‘Depending on their vaccination history, some staff members may need to be monitored or excluded from work during the infectious period to minimise the risk of further transmission – this could be for a period up to 18 days,’ the spokesperson said. ‘Post-exposure prophylaxis may be required and will be organised by the local PHU.’

With the number of cases currently floating around, pharmacists should ensure that staff are up to date with their vaccinations in advance

All adults born between 1966 and 1992 and who do not have documented evidence of vaccination are eligible for a catch-up vaccine to ensure maximum protection against measles, with the two-dose schedule of the MMR vaccine only being introduced in Australia in 1992.

https://twitter.com/VicGovDH/status/1916756251293409486

Should a patient present with a fever and rash, they should be moved out of communal waiting areas and into a dedicated space. If measles is suspected, the patient should be given a disposable, well-sealed mask.
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Responding to a measles exposure in your pharmacy

palliative care

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            [post_content] => Dedicated palliative care training for pharmacists is not commonplace. This PSA-developed course aims to change that. 

It can be difficult to tell from a prescription that a patient is receiving palliative care, said Tanya Maloney MPS, a community pharmacist in Coffs Harbour, NSW.

[caption id="attachment_29354" align="alignright" width="233"] Tanya Maloney MPS[/caption]

‘What we lack in pharmacy is training on how to approach those difficult conversations in the right way so we can ask them a few questions to determine that,’ she said. ‘We're often a bit nervous about saying the wrong thing.’

Though passionate about palliative care, Ms Maloney and her team have had to learn on the job.

‘We haven’t had any extra training and want to know how we can contribute more.’

This is a common issue through the profession, with a lack in palliative care education tailored specifically to pharmacists, leading to a knowledge gap, said PSA Senior Pharmacist (Consulting and Program Delivery) Megan Tremlett MPS – who has managed a number of palliative care projects through Primary Health Networks and at a state level in recent years.

‘As pharmacists, we don't learn a lot about palliative care in our undergraduate course. And the majority of pharmacists haven't done any extra palliative care education since their university days.’

To address this, PSA launched the ASPIRE Palliative Care Foundation Training Program on 13 May. The free, CPD-accredited course – supported by Palliative Care Australia and funded under the National Palliative Care Grants Program – upskills pharmacists regardless of practice setting.

‘The training program has been created with extensive stakeholder consultation to provide pharmacists with a thorough introduction to palliative care across the eight modules’ Ms Tremlett said.

Rather than training pharmacists to specialise in palliative care, the training program is intended to lift the baseline knowledge of the profession, said Leah Robinson, Project Manager at PSA, who worked on the development of the program with Ms Tremlett.

‘It’s about understanding the different settings and phases of palliative care and at which points pharmacists can provide practical support to help families, patients and healthcare professionals in supporting palliative care.’

A foundational understanding of palliative and end-of-life care across the health workforce is essential to meeting community needs, said Camilla Rowland, CEO of Palliative Care Australia.

‘Supporting people to live, and die well, means building palliative care capability across the entire health system. That includes pharmacists, often among the first healthcare professional patients and carers turn to for advice.’
Learning about symptom management
The ASPIRE training program has a module dedicated to symptoms and the trajectory of people living with life-limiting illness. 

Under a subsequent symptom management module, pharmacists can access resources and references for pharmacological management of the symptoms associated with dying that covers:

 	Pharmaceutical Benefits Scheme (PBS) and non-PBS medicines 
 	Special Access Scheme medications
 	Medicines used off-label.

Experts, from pharmacists to prescribers, guide learners on handling sensitive conversations with patients and families – linking to Safer Care Victoria resources for monitoring and managing adverse effects, especially with continuous subcutaneous infusions.
  
‘We point pharmacists to a range of resources to support them with understanding medicines compatibilities in subcutaneous infusion devices and the adverse effects that might be expected,’ Ms Tremlett said.

As illness progresses, medication regimens often grow more complex.

‘Pharmacists need to be able to step in and make recommendations around those [medicines] that could potentially be weaned or stopped to reduce that burden and the chance of side effects and interactions,’ Ms Tremlett said.

The training program also helps pharmacists with information, tools and resources for conversions of medicines and different formulations, including switching from some or all of their opioids, to a replacement opioid delivered by another route, Ms Robinson said. 

‘It’s also [around] practical things pharmacists can offer such as providing a list of current medicines, home medication review, staged supply, support with prescription management, home delivery or flexibility around dose administration aids to help manage those medicines and the complexity of the changes they go through during the different phases of palliative care,’ Ms Robinson said.
Developing interdisciplinary care skills
At the moment, Ms Maloney feels as though community pharmacy is a missing piece in palliative care that’s uncertain where it fits.

‘We want to be able to fit into that wider team of their health carers so we can look at the holistic care and goals of the person and provide them with more than just medication,’ she said.
  
ASPIRE emphasises collaboration with GPs, specialist palliative care teams, community nurses, paramedics and residential aged care staff.

‘In the module that's dedicated to interdisciplinary palliative care, pharmacists learn the broad range of people who are involved in palliative care, and some they might not expect – from death doulas to chaplains, music therapists and diversional therapists,’ Ms Tremlett said.
Focusing on patient-centred care
Once pharmacists identify a palliative care patient, they need knowledge and skills to determine how best to help at each stage, Ms Maloney said.

‘How do we know how to help them in all these different stages that they're going to go through?’

Pharmacists may think they know what’s best for a patient based on their clinical background, Ms Tremlett said.

‘But at the end of the day, what's important to the person or the patient is the single most important thing.’

‘ASPIRE reminds pharmacists to be mindful of their own biases to meet the person where they are and help them achieve their goals of care, which might change over time as their condition progresses,’ Ms Robinson added.

The patient-centred care module also highlights Australia’s cultural diversity – including First Nations peoples, migrants and those from non-English speaking backgrounds.

‘There is no such thing as a consistent cultural need in palliative care,’ Ms Tremlett said.

‘It's very different within cultures, between cultures and within communities, so pharmacists need to be able to adapt the care and services they provide without making assumptions.’

The need for translation services, what’s deemed an inappropriate conversation or who is the next of kin or carer can vary from person to person, Ms Robinson said.

‘It’s important to be mindful of how and what to communicate to align with those goals of care.’
Helping families through grief and bereavement
Being confident talking about death is something many pharmacists struggle with, Ms Maloney said.

‘You might prompt them a little bit, and they do get upset, and that’s often what puts us off,’ she said. ‘But it’s not necessarily a bad thing as they’re getting to open up and talk to you.’

The final ASPIRE module on grief, bereavement and self-care aims to normalise conversations about death and dying. Being comfortable enough to embed those conversations in day-to-day practice – including supporting people after their loved one has died – is crucial, Ms Tremlett said.

‘It's really important for pharmacists to be prepared to still speak about the person who's died, if that's what the person wants to do, and to recognise that grieving is very normal, and there's no right or wrong way to grieve.’

Pharmacists also need to be able to recognise prolonged grief and know when referrals  for extra support are needed.

‘If the pharmacist has the knowledge and skills to refer that person on for some extra help in the grieving process, that's really impactful,’ she said.

Throughout the palliative care process, it’s crucial for pharmacists to look after themselves and to know when to check in on their colleagues too.

‘When we're constantly supporting people who are unwell … it's very natural for pharmacists to feel a burden of care,’ Ms Tremlett said.

‘Learning to recognise when you or your colleagues might be feeling a little overwhelmed, need extra support or to engage in self-care activities is really important.
Embedding the training into practice
Now that the ASPIRE training program is available, Ms Maloney wants all her pharmacists to complete it to lift their confidence and knowledge in palliative care.

‘As part of that, there's all the resources you can print out and revisit,’ she said.

‘They will be active documents that become part of our internal processes rather than training you just do and forget.’

The experience  of supporting palliative care patients also builds trust and loyalty among family members and carers.

‘You get to know them on a different level and see them when they're vulnerable,’ Ms Maloney said. ‘That rapport you can build up in that time by being there for them definitely builds that lifetime customer for the future.’
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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

medicine storage

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            [post_content] => Both Cautionary Advisory Label (CAL) 6 and CAL 13 have been overhauled to sharpen storage advice.

CAL 6 explanatory notes advice in Digital Australian Pharmaceutical Formulary and Handbook (APF) now mentions considerations for room-temperature time windows for refrigerated medicines, while CAL 13’s tightened wording and advice flags truly sensitive formulations – ensuring pharmacists give patients clearer, more precise guidance.
What’s changing?
The familiar ‘Refrigerate, do not freeze’ warning of CAL 6 is not changing, however its explanatory notes have been expanded. 

[caption id="attachment_29335" align="aligncenter" width="180"] CAL 6[/caption]

There are many instances whereby refrigeration of temperature sensitive medicines may not be practical, for example travel days, power outages or ‘in-use’ multi-dose containers/devices. The updated explanatory notes advise pharmacists that they should refer to the medicines approved product information (PI) and counsel their patients on how to best store these medicines – covering when their temperature sensitive medicines may safely remain at room temperature (below 25 °C) – if applicable.

[caption id="attachment_29336" align="aligncenter" width="176"] The old CAL 13[/caption]

[caption id="attachment_29337" align="aligncenter" width="189"] The new CAL 13[/caption]

Meanwhile, CAL 13 has been reworded. Previously ‘Do not remove from original packaging until dose required’, the new prompt, ‘Ask your pharmacist about the storage conditions for this medicine,’ applies only to dosage forms and active ingredients truly sensitive to light, moisture or temperature excursions. 

This includes orally disintegrating tablets, effervescents, sublingual or buccal lozenges, dispersible granules, wafers and chewables, as well as amoxicillin/clavulanic acid, dabigatran, glyceryl trinitrate, nicorandil, nifedipine, phenothiazines, tamoxifen and sodium valproate.

CAL 13 may also be applied in addition to other CALs relating to storage requirements (e.g. CALs 6, 7a or 7b) when complex storage instructions are applicable, and these other CALs do not adequately cover these.

To support the change to CAL 13, the APF’s Good dispensing practice chapter has been updated with clearer and expanded guidance on providing advice to patients on how to store medicines, including that:

 	all medicines should be kept out of sight and out of reach of children at all times
 	unless specifically requiring refrigeration, and in the absence of special storage instructions outlined in the PI/consumer medicine information (CMI), medicines should be stored in their original packaging in a cool (preferably <25 °C), dry and secure place
 	medicines should generally not be removed from their original packaging until a dose is required – pharmacists should check how the patient intends to store their medicines (e.g. in a dosette box) and provide advice according to the storage instructions outlined in each medicines PI/CMI.

CAL 13’s explanatory notes have also been updated in APF Digital to support pharmacists in applying the revised CAL.

When packing medicines into Dose Administration Aids (DAAs) pharmacists should consider the approved PI of each medicine, and PSA’s Guidelines for pharmacists providing dose administration aid services.
What led to this update?
Medicine labels have traditionally relied on simple fridge-or-no-fridge advice. But today’s PIs are more complex. 

Humira (adalimumab) is one good example. People using Humira are advised that they can store single pre-filled syringes or pens ‘below 25°C (room temperature) for a maximum period of 14 days, but must be protected from light. Once removed from the refrigerator for room temperature storage, the syringe must be used within 14 days or discarded, even if it is returned to the refrigerator’. 

But CAL 6 doesn’t capture these nuances, so some patients are left guessing whether their medicines are safe to use or not during travel or at times when refrigeration is not available. The new explanatory notes prompt pharmacists to cover these scenarios as part of their routine counselling to promote safe and quality use of medicines.

At the same time, the CAL 13 had become so ubiquitous – applicable to nearly all medicines – that its impact was diluted. What's more, most pharmacies didn’t even stock the printed sticker. 

By narrowing its application, CAL 13’s power to prompt meaningful conversations about stability risks has been restored.

Above all, when medicines are removed from their original packaging inappropriately, or stored incorrectly, this can translate into reduced potency or patient harm. These refinements give pharmacists clear, evidence-based cues to maintain medicine stability and efficacy. 
How should pharmacists tailor storage advice?
Pharmacists should personalise both verbal and written advice to the patient. Ensure every patient is counselled on how to best store their medicines including routinely asking how the patient plans to keep their medicines, for example will they use a dosette box? Is storage at an appropriate temperature an issue?

If a medicine carries Label 6 but its PI indicates there is an appropriate room-temperature window, demonstrate the correct use of an insulated bag and explain the difference between ‘keep at 2–8 °C’ and ‘store below 25 °C’. Provide guidance on room temperature storage for their in-use multi dose container/device (if appropriate) and for times when refrigeration is unavailable or impractical.

Pharmacists should also advise the patient to avoid storing medicines in the areas of a domestic refrigerator that may not maintain a temperature of 2–8 °C. This includes the door, top shelf or crisper; or within 40 mm of the back and sides of the main compartment.

For CAL-13 affixed medicines, pharmacists should advise patients that these medications’ stability is protected by the original container and packaging, and that removing them prematurely can accelerate degradation and reduce efficacy. Work with the patient to address any barriers to this.
What’s the implementation timeline?
The revised explanatory notes for CAL 6 and CAL 13 are live in APF Digital as of 7 May 2025. 

CAL printers will begin issuing the new CAL 13 labels on their next run. Until then, pharmacists should continue using the existing labels while equipping patients with the updated counselling points and advice outlined in the APF Digital.
How should pharmacists put the new advice into practice?
Let’s say Mrs L, 68, who has type 2 diabetes, atrial fibrillation and hypertension, presents to a pharmacy for her medicines. She picks up a prescription for insulin glargine pens, nifedipine and dabigatran. For her insulin glargine, you apply Label 6 and explain the medicine must be stored at 2–8 °C in the fridge’s main compartment, yet the in-use pen may remain at room temperature for up to 28 days. You provide her with an insulated bag and demonstrate how to use it.

You then recognise that nifedipine is sensitive to light and dabigatran is moisture-sensitive, and apply Label 13 to each medicine’s packaging which prompts a PI check. You advise her to keep the medicines away from humid spots such as bathrooms or kitchen windowsills, and to keep them in their original packaging, out of direct light. Mrs L leaves confident in where to store each medicine, and you’ve pre-emptively safeguarded stability and efficacy.
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New CAL medicine storage guidance

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            [post_content] => Merging CAL 18 and CAL I removes duplication and confusion, helping patients receive clearer, more actionable dietary advice.

Australian Pharmacist explores what pharmacists and patients need to know.

What’s changing?

Cautionary advisory label (CAL) 18 and CAL I currently provide dietary advice for specific medicines:

[caption id="attachment_29312" align="aligncenter" width="151"] CAL 18[/caption]

[caption id="attachment_29311" align="aligncenter" width="152"] CAL I[/caption]
Instead of having two labels that relate to avoiding certain foods and juices (CAL 18 and CAL I), there will now be one – an updated CAL 18.


[caption id="attachment_29313" align="aligncenter" width="189"] Revised CAL 18[/caption]
What’s the rationale?
Currently, CAL 18 only warns about grapefruit due to its effect on the bioavailability of certain medicines through the selective inhibition of cytochrome P450 3A4 isoenzymes. But the product information (PI) for new medicines that are substrates for CYP3A4 increasingly mention other fruits (beyond just grapefruit) as interacting with medicines via inhibition of CYP3A4. This includes seville oranges, pomelo, star fruit, bitter melon and pomegranate. 

As it stands, the wording of CAL 18 is not broad enough to cover these scenarios.

CAL I is currently used to advise patients about fruits and juices that interact with medicines through mechanisms other than inhibition of CYP3A4. 

For example, food and drink interactions with non-selective monoamine oxidase inhibitors (MAOIs) and interactions between medicines and fruit juices through mechanisms other than CYP3A4 inhibition (e.g. fexofenadine, which has been found to interact with orange and apple juice). 

However, there have been reports of confusion associated with ‘I’ appearing very similar to ‘1’ in the CAL recommendation table. There are also not many medicines CAL I is relevant to at present, so it therefore has limited applicability. 

The revised CAL 18, now reading ‘Certain foods and fruit juices should be avoided while being treated with this medicine’, will now cover:

 	interactions with all CYP3A4-inhibiting fruits (for example, grapefruit, Seville orange, pomelo, pomegranate, star fruit) 
 	any newly identified food and juice interactions with medicines – even those that don’t occur by CYP3A4 (e.g. apple and orange juice); and
 	other food and drink interactions with medicines (e.g. foods and drinks rich in tyramine with MAOIs).

How should pharmacists respond when patients ask which foods and fruit juices should be avoided?
For those fruits that can inhibit CYP3A4 (e.g. grapefruit, Seville orange, pomelo, star fruit, bitter melon and pomegranate), this can lead to higher drug levels and potential toxicity of relevant CYP3A4 substrates. Pharmacists should advise patients that these fruits should be avoided in any form (e.g. fruit or juice) with these medicines as there is no recommendation on the quantity that can be safely consumed.

Beyond CYP3A4 substrates, it becomes more nuanced. For example, atenolol and fexofenadine aren’t metabolised by CYP3A4, yet both can have reduced bioavailability when taken with apple or orange juice – so patients taking these medicines should be advised to avoid these juices.

When dispensing MAOIs, pharmacists should counsel patients to avoid tyramine-rich foods such as aged cheeses, cured meats, fermented products, yeast extract products and beer. Other certain foods and drinks must be consumed only in small amounts. MAOIs block the enzyme that normally breaks down tyramine, causing it to accumulate in the bloodstream, which can lead to a hypertensive crisis. Pharmacists should provide an MAOI card to patients, see APF Digital – Counselling advice for monoamine oxidase inhibitors. 

It is important that pharmacists check a medicines’ approved PI to confirm the specific foods, fruits and juices that patients should avoid. Appropriate drug interaction resources (e.g. Stockley’s Drug Interactions) should also be used where needed when providing medicine-specific advice.
When is the change happening?
The CAL explanatory notes were updated in APF Digital today (7 May 2025).

Pharmacists should familiarise themselves with the revised explanatory notes for CAL 18 in the digital Australian Pharmaceutical Formulary and Handbook.
When will dispensing software be updated with the revised CALs?
Pharmacists are advised to talk to their dispensing software provider, who can advise when these changes will be implemented.
When will the new labels arrive?
It is anticipated printers will commence printing of the new labels during their next print run.

Until then, pharmacists should use the existing CAL 18 and CAL I – ensuring patients are equipped with the updated advice, available now in APF Digital which always contains the latest updates.
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Goodbye CAL I, hello expanded CAL 18

measles

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            [post_content] => With measles cases climbing across Australia and pharmacies increasingly listed as exposure sites, community pharmacists must be prepared.


Earlier this year, a patient who had just returned from Vietnam walked into Advantage Chesterville Pharmacy in Melbourne with a script for antibiotics.

‘She was wearing a face mask, and when I spoke to her she just said that she had a cough but she wasn't sure what the cough was from,’ said community pharmacist Minh Ngo MPS, who was on duty when the patient came through.

Some time later, the pharmacy received word that the patient was infected with measles.

‘She either informed the hospital or the GP, but we just got a call from the [Victorian] Department of Health to notify us that we were an exposure case,’ she said.

With measles spreading around Australia at an unprecedented rate, this is a position many pharmacists may soon find themselves in.

Victoria is in the midst of its worst measles outbreak in a decade, with 25 cases recorded so far this year. New South Wales and Western Australia are not far behind, with 21 and 18 cases reported respectively.

Healthcare settings such as pharmacies have been increasingly listed as exposure sites as people seek treatment for the highly infectious and virulent disease.

Australian Pharmacist explores the steps pharmacists should take when confronted with this predicament.
Patient contact tracing
When a healthcare setting such as a pharmacy becomes a measles exposure site, it is responsible for contact tracing.

‘We had to inform every patient who was in the [pharmacy] at that time that we were informed that the exposure might have happened,’ Ms Ngo said. 

This includes asking patients if they have any symptoms. Early symptoms of measles, before the rash appears, include:

 	fever 
 	tiredness 
 	cough 
 	runny nose
 	sore red eyes 
 	malaise.

‘We had to inform every patient who was in the [pharmacy] at that time that we were informed that the exposure might have happened.'

MINH NGO MPS  
Post-exposure testing and prophylaxis
All symptomatic patients who were exposed to measles need to follow specific protocols. 

‘We told them that if they have any symptoms, if they develop any cough or if they have any concerns then go and get tested,’ Ms Ngo said. 

Patients who have attended a known exposure site should be offered the Measles, Mumps, and Rubella vaccine within 72 hours of measles exposure to avert infection. In those who are unvaccinated or partially vaccinated, particularly young infants, pregnant people,, or immunocompromised patients – human immunoglobulin (NHIG) administered within six days of exposure may be appropriate.

Pharmacists should advise patients with suspected measles to call ahead before visiting their healthcare provider for a PCR test and wear a mask upon leaving home. Suspected cases must remain isolated at home until laboratory testing confirms or excludes measles, avoiding work, school and any public venues.

A notification must be made to the relevant department of health when symptoms are present via the patients' local public health unit.
Important staff protocols
Fortunately, there were only two members of staff on at the pharmacy including Ms Ngo at the time of the exposure, and neither was infected with measles.

Local PHUs will identify any staff who may have been exposed to a measles case and assess their immunity status, said a spokesperson from the federal Department of Health and Aged Care. 

‘Depending on their vaccination history, some staff members may need to be monitored or excluded from work during the infectious period to minimise the risk of further transmission – this could be for a period up to 18 days,’ the spokesperson said. ‘Post-exposure prophylaxis may be required and will be organised by the local PHU.’

With the number of cases currently floating around, pharmacists should ensure that staff are up to date with their vaccinations in advance

All adults born between 1966 and 1992 and who do not have documented evidence of vaccination are eligible for a catch-up vaccine to ensure maximum protection against measles, with the two-dose schedule of the MMR vaccine only being introduced in Australia in 1992.

https://twitter.com/VicGovDH/status/1916756251293409486

Should a patient present with a fever and rash, they should be moved out of communal waiting areas and into a dedicated space. If measles is suspected, the patient should be given a disposable, well-sealed mask.
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Responding to a measles exposure in your pharmacy

palliative care

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            [post_content] => Dedicated palliative care training for pharmacists is not commonplace. This PSA-developed course aims to change that. 

It can be difficult to tell from a prescription that a patient is receiving palliative care, said Tanya Maloney MPS, a community pharmacist in Coffs Harbour, NSW.

[caption id="attachment_29354" align="alignright" width="233"] Tanya Maloney MPS[/caption]

‘What we lack in pharmacy is training on how to approach those difficult conversations in the right way so we can ask them a few questions to determine that,’ she said. ‘We're often a bit nervous about saying the wrong thing.’

Though passionate about palliative care, Ms Maloney and her team have had to learn on the job.

‘We haven’t had any extra training and want to know how we can contribute more.’

This is a common issue through the profession, with a lack in palliative care education tailored specifically to pharmacists, leading to a knowledge gap, said PSA Senior Pharmacist (Consulting and Program Delivery) Megan Tremlett MPS – who has managed a number of palliative care projects through Primary Health Networks and at a state level in recent years.

‘As pharmacists, we don't learn a lot about palliative care in our undergraduate course. And the majority of pharmacists haven't done any extra palliative care education since their university days.’

To address this, PSA launched the ASPIRE Palliative Care Foundation Training Program on 13 May. The free, CPD-accredited course – supported by Palliative Care Australia and funded under the National Palliative Care Grants Program – upskills pharmacists regardless of practice setting.

‘The training program has been created with extensive stakeholder consultation to provide pharmacists with a thorough introduction to palliative care across the eight modules’ Ms Tremlett said.

Rather than training pharmacists to specialise in palliative care, the training program is intended to lift the baseline knowledge of the profession, said Leah Robinson, Project Manager at PSA, who worked on the development of the program with Ms Tremlett.

‘It’s about understanding the different settings and phases of palliative care and at which points pharmacists can provide practical support to help families, patients and healthcare professionals in supporting palliative care.’

A foundational understanding of palliative and end-of-life care across the health workforce is essential to meeting community needs, said Camilla Rowland, CEO of Palliative Care Australia.

‘Supporting people to live, and die well, means building palliative care capability across the entire health system. That includes pharmacists, often among the first healthcare professional patients and carers turn to for advice.’
Learning about symptom management
The ASPIRE training program has a module dedicated to symptoms and the trajectory of people living with life-limiting illness. 

Under a subsequent symptom management module, pharmacists can access resources and references for pharmacological management of the symptoms associated with dying that covers:

 	Pharmaceutical Benefits Scheme (PBS) and non-PBS medicines 
 	Special Access Scheme medications
 	Medicines used off-label.

Experts, from pharmacists to prescribers, guide learners on handling sensitive conversations with patients and families – linking to Safer Care Victoria resources for monitoring and managing adverse effects, especially with continuous subcutaneous infusions.
  
‘We point pharmacists to a range of resources to support them with understanding medicines compatibilities in subcutaneous infusion devices and the adverse effects that might be expected,’ Ms Tremlett said.

As illness progresses, medication regimens often grow more complex.

‘Pharmacists need to be able to step in and make recommendations around those [medicines] that could potentially be weaned or stopped to reduce that burden and the chance of side effects and interactions,’ Ms Tremlett said.

The training program also helps pharmacists with information, tools and resources for conversions of medicines and different formulations, including switching from some or all of their opioids, to a replacement opioid delivered by another route, Ms Robinson said. 

‘It’s also [around] practical things pharmacists can offer such as providing a list of current medicines, home medication review, staged supply, support with prescription management, home delivery or flexibility around dose administration aids to help manage those medicines and the complexity of the changes they go through during the different phases of palliative care,’ Ms Robinson said.
Developing interdisciplinary care skills
At the moment, Ms Maloney feels as though community pharmacy is a missing piece in palliative care that’s uncertain where it fits.

‘We want to be able to fit into that wider team of their health carers so we can look at the holistic care and goals of the person and provide them with more than just medication,’ she said.
  
ASPIRE emphasises collaboration with GPs, specialist palliative care teams, community nurses, paramedics and residential aged care staff.

‘In the module that's dedicated to interdisciplinary palliative care, pharmacists learn the broad range of people who are involved in palliative care, and some they might not expect – from death doulas to chaplains, music therapists and diversional therapists,’ Ms Tremlett said.
Focusing on patient-centred care
Once pharmacists identify a palliative care patient, they need knowledge and skills to determine how best to help at each stage, Ms Maloney said.

‘How do we know how to help them in all these different stages that they're going to go through?’

Pharmacists may think they know what’s best for a patient based on their clinical background, Ms Tremlett said.

‘But at the end of the day, what's important to the person or the patient is the single most important thing.’

‘ASPIRE reminds pharmacists to be mindful of their own biases to meet the person where they are and help them achieve their goals of care, which might change over time as their condition progresses,’ Ms Robinson added.

The patient-centred care module also highlights Australia’s cultural diversity – including First Nations peoples, migrants and those from non-English speaking backgrounds.

‘There is no such thing as a consistent cultural need in palliative care,’ Ms Tremlett said.

‘It's very different within cultures, between cultures and within communities, so pharmacists need to be able to adapt the care and services they provide without making assumptions.’

The need for translation services, what’s deemed an inappropriate conversation or who is the next of kin or carer can vary from person to person, Ms Robinson said.

‘It’s important to be mindful of how and what to communicate to align with those goals of care.’
Helping families through grief and bereavement
Being confident talking about death is something many pharmacists struggle with, Ms Maloney said.

‘You might prompt them a little bit, and they do get upset, and that’s often what puts us off,’ she said. ‘But it’s not necessarily a bad thing as they’re getting to open up and talk to you.’

The final ASPIRE module on grief, bereavement and self-care aims to normalise conversations about death and dying. Being comfortable enough to embed those conversations in day-to-day practice – including supporting people after their loved one has died – is crucial, Ms Tremlett said.

‘It's really important for pharmacists to be prepared to still speak about the person who's died, if that's what the person wants to do, and to recognise that grieving is very normal, and there's no right or wrong way to grieve.’

Pharmacists also need to be able to recognise prolonged grief and know when referrals  for extra support are needed.

‘If the pharmacist has the knowledge and skills to refer that person on for some extra help in the grieving process, that's really impactful,’ she said.

Throughout the palliative care process, it’s crucial for pharmacists to look after themselves and to know when to check in on their colleagues too.

‘When we're constantly supporting people who are unwell … it's very natural for pharmacists to feel a burden of care,’ Ms Tremlett said.

‘Learning to recognise when you or your colleagues might be feeling a little overwhelmed, need extra support or to engage in self-care activities is really important.
Embedding the training into practice
Now that the ASPIRE training program is available, Ms Maloney wants all her pharmacists to complete it to lift their confidence and knowledge in palliative care.

‘As part of that, there's all the resources you can print out and revisit,’ she said.

‘They will be active documents that become part of our internal processes rather than training you just do and forget.’

The experience  of supporting palliative care patients also builds trust and loyalty among family members and carers.

‘You get to know them on a different level and see them when they're vulnerable,’ Ms Maloney said. ‘That rapport you can build up in that time by being there for them definitely builds that lifetime customer for the future.’
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            [post_excerpt] => Dedicated palliative care training for pharmacists is not commonplace. This PSA-developed course aims to change that. 
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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

medicine storage

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            [post_content] => Both Cautionary Advisory Label (CAL) 6 and CAL 13 have been overhauled to sharpen storage advice.

CAL 6 explanatory notes advice in Digital Australian Pharmaceutical Formulary and Handbook (APF) now mentions considerations for room-temperature time windows for refrigerated medicines, while CAL 13’s tightened wording and advice flags truly sensitive formulations – ensuring pharmacists give patients clearer, more precise guidance.
What’s changing?
The familiar ‘Refrigerate, do not freeze’ warning of CAL 6 is not changing, however its explanatory notes have been expanded. 

[caption id="attachment_29335" align="aligncenter" width="180"] CAL 6[/caption]

There are many instances whereby refrigeration of temperature sensitive medicines may not be practical, for example travel days, power outages or ‘in-use’ multi-dose containers/devices. The updated explanatory notes advise pharmacists that they should refer to the medicines approved product information (PI) and counsel their patients on how to best store these medicines – covering when their temperature sensitive medicines may safely remain at room temperature (below 25 °C) – if applicable.

[caption id="attachment_29336" align="aligncenter" width="176"] The old CAL 13[/caption]

[caption id="attachment_29337" align="aligncenter" width="189"] The new CAL 13[/caption]

Meanwhile, CAL 13 has been reworded. Previously ‘Do not remove from original packaging until dose required’, the new prompt, ‘Ask your pharmacist about the storage conditions for this medicine,’ applies only to dosage forms and active ingredients truly sensitive to light, moisture or temperature excursions. 

This includes orally disintegrating tablets, effervescents, sublingual or buccal lozenges, dispersible granules, wafers and chewables, as well as amoxicillin/clavulanic acid, dabigatran, glyceryl trinitrate, nicorandil, nifedipine, phenothiazines, tamoxifen and sodium valproate.

CAL 13 may also be applied in addition to other CALs relating to storage requirements (e.g. CALs 6, 7a or 7b) when complex storage instructions are applicable, and these other CALs do not adequately cover these.

To support the change to CAL 13, the APF’s Good dispensing practice chapter has been updated with clearer and expanded guidance on providing advice to patients on how to store medicines, including that:

 	all medicines should be kept out of sight and out of reach of children at all times
 	unless specifically requiring refrigeration, and in the absence of special storage instructions outlined in the PI/consumer medicine information (CMI), medicines should be stored in their original packaging in a cool (preferably <25 °C), dry and secure place
 	medicines should generally not be removed from their original packaging until a dose is required – pharmacists should check how the patient intends to store their medicines (e.g. in a dosette box) and provide advice according to the storage instructions outlined in each medicines PI/CMI.

CAL 13’s explanatory notes have also been updated in APF Digital to support pharmacists in applying the revised CAL.

When packing medicines into Dose Administration Aids (DAAs) pharmacists should consider the approved PI of each medicine, and PSA’s Guidelines for pharmacists providing dose administration aid services.
What led to this update?
Medicine labels have traditionally relied on simple fridge-or-no-fridge advice. But today’s PIs are more complex. 

Humira (adalimumab) is one good example. People using Humira are advised that they can store single pre-filled syringes or pens ‘below 25°C (room temperature) for a maximum period of 14 days, but must be protected from light. Once removed from the refrigerator for room temperature storage, the syringe must be used within 14 days or discarded, even if it is returned to the refrigerator’. 

But CAL 6 doesn’t capture these nuances, so some patients are left guessing whether their medicines are safe to use or not during travel or at times when refrigeration is not available. The new explanatory notes prompt pharmacists to cover these scenarios as part of their routine counselling to promote safe and quality use of medicines.

At the same time, the CAL 13 had become so ubiquitous – applicable to nearly all medicines – that its impact was diluted. What's more, most pharmacies didn’t even stock the printed sticker. 

By narrowing its application, CAL 13’s power to prompt meaningful conversations about stability risks has been restored.

Above all, when medicines are removed from their original packaging inappropriately, or stored incorrectly, this can translate into reduced potency or patient harm. These refinements give pharmacists clear, evidence-based cues to maintain medicine stability and efficacy. 
How should pharmacists tailor storage advice?
Pharmacists should personalise both verbal and written advice to the patient. Ensure every patient is counselled on how to best store their medicines including routinely asking how the patient plans to keep their medicines, for example will they use a dosette box? Is storage at an appropriate temperature an issue?

If a medicine carries Label 6 but its PI indicates there is an appropriate room-temperature window, demonstrate the correct use of an insulated bag and explain the difference between ‘keep at 2–8 °C’ and ‘store below 25 °C’. Provide guidance on room temperature storage for their in-use multi dose container/device (if appropriate) and for times when refrigeration is unavailable or impractical.

Pharmacists should also advise the patient to avoid storing medicines in the areas of a domestic refrigerator that may not maintain a temperature of 2–8 °C. This includes the door, top shelf or crisper; or within 40 mm of the back and sides of the main compartment.

For CAL-13 affixed medicines, pharmacists should advise patients that these medications’ stability is protected by the original container and packaging, and that removing them prematurely can accelerate degradation and reduce efficacy. Work with the patient to address any barriers to this.
What’s the implementation timeline?
The revised explanatory notes for CAL 6 and CAL 13 are live in APF Digital as of 7 May 2025. 

CAL printers will begin issuing the new CAL 13 labels on their next run. Until then, pharmacists should continue using the existing labels while equipping patients with the updated counselling points and advice outlined in the APF Digital.
How should pharmacists put the new advice into practice?
Let’s say Mrs L, 68, who has type 2 diabetes, atrial fibrillation and hypertension, presents to a pharmacy for her medicines. She picks up a prescription for insulin glargine pens, nifedipine and dabigatran. For her insulin glargine, you apply Label 6 and explain the medicine must be stored at 2–8 °C in the fridge’s main compartment, yet the in-use pen may remain at room temperature for up to 28 days. You provide her with an insulated bag and demonstrate how to use it.

You then recognise that nifedipine is sensitive to light and dabigatran is moisture-sensitive, and apply Label 13 to each medicine’s packaging which prompts a PI check. You advise her to keep the medicines away from humid spots such as bathrooms or kitchen windowsills, and to keep them in their original packaging, out of direct light. Mrs L leaves confident in where to store each medicine, and you’ve pre-emptively safeguarded stability and efficacy.
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New CAL medicine storage guidance

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            [post_content] => Merging CAL 18 and CAL I removes duplication and confusion, helping patients receive clearer, more actionable dietary advice.

Australian Pharmacist explores what pharmacists and patients need to know.

What’s changing?

Cautionary advisory label (CAL) 18 and CAL I currently provide dietary advice for specific medicines:

[caption id="attachment_29312" align="aligncenter" width="151"] CAL 18[/caption]

[caption id="attachment_29311" align="aligncenter" width="152"] CAL I[/caption]
Instead of having two labels that relate to avoiding certain foods and juices (CAL 18 and CAL I), there will now be one – an updated CAL 18.


[caption id="attachment_29313" align="aligncenter" width="189"] Revised CAL 18[/caption]
What’s the rationale?
Currently, CAL 18 only warns about grapefruit due to its effect on the bioavailability of certain medicines through the selective inhibition of cytochrome P450 3A4 isoenzymes. But the product information (PI) for new medicines that are substrates for CYP3A4 increasingly mention other fruits (beyond just grapefruit) as interacting with medicines via inhibition of CYP3A4. This includes seville oranges, pomelo, star fruit, bitter melon and pomegranate. 

As it stands, the wording of CAL 18 is not broad enough to cover these scenarios.

CAL I is currently used to advise patients about fruits and juices that interact with medicines through mechanisms other than inhibition of CYP3A4. 

For example, food and drink interactions with non-selective monoamine oxidase inhibitors (MAOIs) and interactions between medicines and fruit juices through mechanisms other than CYP3A4 inhibition (e.g. fexofenadine, which has been found to interact with orange and apple juice). 

However, there have been reports of confusion associated with ‘I’ appearing very similar to ‘1’ in the CAL recommendation table. There are also not many medicines CAL I is relevant to at present, so it therefore has limited applicability. 

The revised CAL 18, now reading ‘Certain foods and fruit juices should be avoided while being treated with this medicine’, will now cover:

 	interactions with all CYP3A4-inhibiting fruits (for example, grapefruit, Seville orange, pomelo, pomegranate, star fruit) 
 	any newly identified food and juice interactions with medicines – even those that don’t occur by CYP3A4 (e.g. apple and orange juice); and
 	other food and drink interactions with medicines (e.g. foods and drinks rich in tyramine with MAOIs).

How should pharmacists respond when patients ask which foods and fruit juices should be avoided?
For those fruits that can inhibit CYP3A4 (e.g. grapefruit, Seville orange, pomelo, star fruit, bitter melon and pomegranate), this can lead to higher drug levels and potential toxicity of relevant CYP3A4 substrates. Pharmacists should advise patients that these fruits should be avoided in any form (e.g. fruit or juice) with these medicines as there is no recommendation on the quantity that can be safely consumed.

Beyond CYP3A4 substrates, it becomes more nuanced. For example, atenolol and fexofenadine aren’t metabolised by CYP3A4, yet both can have reduced bioavailability when taken with apple or orange juice – so patients taking these medicines should be advised to avoid these juices.

When dispensing MAOIs, pharmacists should counsel patients to avoid tyramine-rich foods such as aged cheeses, cured meats, fermented products, yeast extract products and beer. Other certain foods and drinks must be consumed only in small amounts. MAOIs block the enzyme that normally breaks down tyramine, causing it to accumulate in the bloodstream, which can lead to a hypertensive crisis. Pharmacists should provide an MAOI card to patients, see APF Digital – Counselling advice for monoamine oxidase inhibitors. 

It is important that pharmacists check a medicines’ approved PI to confirm the specific foods, fruits and juices that patients should avoid. Appropriate drug interaction resources (e.g. Stockley’s Drug Interactions) should also be used where needed when providing medicine-specific advice.
When is the change happening?
The CAL explanatory notes were updated in APF Digital today (7 May 2025).

Pharmacists should familiarise themselves with the revised explanatory notes for CAL 18 in the digital Australian Pharmaceutical Formulary and Handbook.
When will dispensing software be updated with the revised CALs?
Pharmacists are advised to talk to their dispensing software provider, who can advise when these changes will be implemented.
When will the new labels arrive?
It is anticipated printers will commence printing of the new labels during their next print run.

Until then, pharmacists should use the existing CAL 18 and CAL I – ensuring patients are equipped with the updated advice, available now in APF Digital which always contains the latest updates.
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Goodbye CAL I, hello expanded CAL 18

measles

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            [post_content] => With measles cases climbing across Australia and pharmacies increasingly listed as exposure sites, community pharmacists must be prepared.


Earlier this year, a patient who had just returned from Vietnam walked into Advantage Chesterville Pharmacy in Melbourne with a script for antibiotics.

‘She was wearing a face mask, and when I spoke to her she just said that she had a cough but she wasn't sure what the cough was from,’ said community pharmacist Minh Ngo MPS, who was on duty when the patient came through.

Some time later, the pharmacy received word that the patient was infected with measles.

‘She either informed the hospital or the GP, but we just got a call from the [Victorian] Department of Health to notify us that we were an exposure case,’ she said.

With measles spreading around Australia at an unprecedented rate, this is a position many pharmacists may soon find themselves in.

Victoria is in the midst of its worst measles outbreak in a decade, with 25 cases recorded so far this year. New South Wales and Western Australia are not far behind, with 21 and 18 cases reported respectively.

Healthcare settings such as pharmacies have been increasingly listed as exposure sites as people seek treatment for the highly infectious and virulent disease.

Australian Pharmacist explores the steps pharmacists should take when confronted with this predicament.
Patient contact tracing
When a healthcare setting such as a pharmacy becomes a measles exposure site, it is responsible for contact tracing.

‘We had to inform every patient who was in the [pharmacy] at that time that we were informed that the exposure might have happened,’ Ms Ngo said. 

This includes asking patients if they have any symptoms. Early symptoms of measles, before the rash appears, include:

 	fever 
 	tiredness 
 	cough 
 	runny nose
 	sore red eyes 
 	malaise.

‘We had to inform every patient who was in the [pharmacy] at that time that we were informed that the exposure might have happened.'

MINH NGO MPS  
Post-exposure testing and prophylaxis
All symptomatic patients who were exposed to measles need to follow specific protocols. 

‘We told them that if they have any symptoms, if they develop any cough or if they have any concerns then go and get tested,’ Ms Ngo said. 

Patients who have attended a known exposure site should be offered the Measles, Mumps, and Rubella vaccine within 72 hours of measles exposure to avert infection. In those who are unvaccinated or partially vaccinated, particularly young infants, pregnant people,, or immunocompromised patients – human immunoglobulin (NHIG) administered within six days of exposure may be appropriate.

Pharmacists should advise patients with suspected measles to call ahead before visiting their healthcare provider for a PCR test and wear a mask upon leaving home. Suspected cases must remain isolated at home until laboratory testing confirms or excludes measles, avoiding work, school and any public venues.

A notification must be made to the relevant department of health when symptoms are present via the patients' local public health unit.
Important staff protocols
Fortunately, there were only two members of staff on at the pharmacy including Ms Ngo at the time of the exposure, and neither was infected with measles.

Local PHUs will identify any staff who may have been exposed to a measles case and assess their immunity status, said a spokesperson from the federal Department of Health and Aged Care. 

‘Depending on their vaccination history, some staff members may need to be monitored or excluded from work during the infectious period to minimise the risk of further transmission – this could be for a period up to 18 days,’ the spokesperson said. ‘Post-exposure prophylaxis may be required and will be organised by the local PHU.’

With the number of cases currently floating around, pharmacists should ensure that staff are up to date with their vaccinations in advance

All adults born between 1966 and 1992 and who do not have documented evidence of vaccination are eligible for a catch-up vaccine to ensure maximum protection against measles, with the two-dose schedule of the MMR vaccine only being introduced in Australia in 1992.

https://twitter.com/VicGovDH/status/1916756251293409486

Should a patient present with a fever and rash, they should be moved out of communal waiting areas and into a dedicated space. If measles is suspected, the patient should be given a disposable, well-sealed mask.
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Responding to a measles exposure in your pharmacy

Australian Pharmacist

Beware online parenting forums

Sian Powell - May 15, 2000

Practice

1...297298299 Page 298 of 299

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