Improving communication of medication changes using a pharmacist-prepared discharge medication management summary

Abstract

Background Discontinuity of care between hospital and primary care is often due to poor information transfer. Medication information in medical discharge summaries (DS) is often incomplete or incorrect. The effectiveness and feasibility of hospital pharmacists communicating medication information, including changes made in the hospital, is not clearly defined. Objective To explore the impact of a pharmacist-prepared Discharge Medication Management Summary (DMMS) on the accuracy of information about medication changes provided to patients' general practitioners (GPs). Setting Two medical wards at a major metropolitan hospital in Australia. Method An intervention was developed in which ward pharmacists communicated medication change information to GPs using the DMMS. Retrospective audits were conducted at baseline and after implementation of the DMMS to compare the accuracy of information provided by doctors and pharmacists. GPs' satisfaction with the DMMS was assessed through a faxed survey. Main outcome measure Accuracy of medication change information communicated to GPs; GP satisfaction and feasibility of a pharmacist-prepared DMMS. Results At baseline, 263/573 (45.9%) medication changes were documented by doctors in the DS. In the post-intervention audit, more medication changes were documented in the pharmacist-prepared DMMS compared to the doctor-prepared DS (72.8% vs. 31.5%; p < 0.001). Most GPs (73.3%) were satisfied with the information provided and wanted to receive the DMMS in the future. Completing the DMMS took pharmacists an average of 11.7 minutes. Conclusion The accuracy of medication information transferred upon discharge can be improved by expanding the role of hospital pharmacists to include documenting medication changes.

Pharmacist–Physician Collaboration to Improve the Accuracy of Medication Information in Electronic Medical Discharge Summaries: Effectiveness and Sustainability

“…Failure to mention changes makes it difficult for the primary care physician to know whether they were intentional or accidental, and failure to explain the reasons for medication changes makes it difficult for them to know whether to re-start a ceased medication, whether to continue a new medication, whether to titrate the dose, what the treatment goal is and what outcomes to monitor. This is particularly relevant in cases where the reason(s) may not be obvious [24].…”

“…Yet this pharmacist-generated information is not routinely shared with primary care physicians. A study by Ooi et al [24] reported that the option to receive a pharmacist-prepared summary of medication changes made in the hospital was an approach that many primary care physicians preferred and were satisfied with. In our study, when pharmacists contributed to discharge summaries, around 80% of clinically significant medication changes were stated in the EDS, and around two-thirds were both stated and explained.…”

“…There is evidence that pharmacists can prepare discharge medication information with a high degree of accuracy [10,19,20], and that pharmacist-led medication reconciliation leads to fewer medication discrepancies at discharge [21]. A number of studies have highlighted the benefits of involving pharmacists in preparing medical discharge summaries [18,[22][23][24][25]. Studies by Alex et al [18], Bergvist et al [22] and Tong et al [23] demonstrated that pharmacists' input into discharge summaries led to more accurate medication lists, while studies by Ooi et al [24] and Duedahl et al [25] demonstrated that pharmacists' input led to more accurate information about medication changes.…”

“…A number of studies have highlighted the benefits of involving pharmacists in preparing medical discharge summaries [18,[22][23][24][25]. Studies by Alex et al [18], Bergvist et al [22] and Tong et al [23] demonstrated that pharmacists' input into discharge summaries led to more accurate medication lists, while studies by Ooi et al [24] and Duedahl et al [25] demonstrated that pharmacists' input led to more accurate information about medication changes. In their randomised controlled trial, Tong et al [23] reported an absolute risk reduction of 46.5% for medication list errors when pharmacists completed the medication section of patients' discharge summaries, compared with standard physician-prepared discharge summaries.…”

“…In their randomised controlled trial, Tong et al [23] reported an absolute risk reduction of 46.5% for medication list errors when pharmacists completed the medication section of patients' discharge summaries, compared with standard physician-prepared discharge summaries. Ooi et al [24] reported that a greater proportion of medication changes were documented in pharmacist-prepared discharge medication summaries compared with physician-prepared discharge summaries (72.8% vs. 31.5%).…”