Pharmacist Involvement in Care Transitions in an Academic Medical Center

Background Care transitions pose increased risks for medication errors Pharmacists are uniquely suited to provide assistance with medication reconciliations and medication counseling during care transitions Objective The primary objective of this study was to evaluate the impact of a pharmacist reviewing discharge medication reconciliations and providing medication counseling at the time of hospital discharge Methods This retrospective chart review includes adult patients discharged from a range of medicine services from August to February at a large academic medical center The primary outcome was day hospital readmission rate and secondary outcomes included time to hospital readmission frequency of medication errors type of medication errors and frequency of errors per pharmacologic class Results In the final analysis patients were included The majority of patients in the intervention group had at least one medication error and the most common error occurred with cardiovascular agents There was no statistically significant difference between the two groups regarding day hospital readmissions Conclusion Although the findings did not show significant differences a pharmacist was able to identify medication errors in most patients Additionally a lack of difference in hospital readmissions is clinically significant given the intervention group had higher acuity of health care needs