Pharmacist-led program to improve transitions from acute care to skilled nursing facility care.

Maria Achilleos; Jordan McEwen; Megan Hoesly; Mark DeAngelo; Tim Jennings

Study

Pharmacist-led program to improve transitions from acute care to skilled nursing facility care.

July 8, 2020

Achilleos M, McEwen J, Hoesly M, et al. Am J Health Syst Pharm. 2020;77(12).

View more articles from the same authors.

Pharmacists are critical to ensuring safe transitions between acute care and skilled nursing facilities (SNFs). This retrospective study evaluated the frequency of missed doses of high-risk medications after hospital-to-SNF transfers and found that 60% of first doses of high-risk medications were given after the scheduled administration time. After implementation of a medication order process including pharmacist-led medication reconciliation, the average delay in medication administration decreased significantly.

PubMed citation

Available at

Related Resources From the Same Author(s)

Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system.

December 12, 2021

Workforce planning and safe workload in sterile compounding hospital pharmacy services.

November 24, 2021

Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital

August 25, 2021

Improving the specificity of drug-drug interaction alerts: can it be done?

April 6, 2022

Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.

August 5, 2020

Medication adverse events in the ambulatory setting: a mixed-methods analysis.

October 26, 2022

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing-2019.

September 30, 2020

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

February 12, 2020

Weight and size descriptors for drug dosing: too many options and too many errors.

January 11, 2023

ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical services and workforce-2021.

October 19, 2022

Impact of clinical decision support therapeutic interchanges on hospital discharge medication omissions and duplications.

October 20, 2021

Burnout and secondary traumatic stress in health-system pharmacists during the COVID-19 pandemic.

June 30, 2021

National drug shortages worsen during COVID-19 crisis: proposal for a comprehensive model to monitor and address critical drug shortages.

November 4, 2020

ASHP Guidelines on the Safe Use of Automated Compounding Devices for the Preparation of Parenteral Nutrition Admixtures.

June 15, 2022

Accuracy and safety of medication histories obtained at the time of intensive care unit admission of delirious or mechanically ventilated patients.

April 28, 2021

Impact of an electronic health record alert on inappropriate prescribing of high-risk medications to patients with concurrent "do not give" orders.

August 3, 2022

ASHP statement on the pharmacist's role in medication reconciliation.

February 27, 2013

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

September 23, 2020

ASHP Standard for Certification as a Center of Excellence in Medication-Use Safety and Pharmacy Practice.

April 20, 2022

Multicenter study to evaluate the benefits of technology-assisted workflow on i.v. room efficiency, costs, and safety.

June 26, 2019

ASHP Guidelines on Preventing Diversion of Controlled Substances.

December 14, 2022

Insulin Pens Devices.

October 12, 2016

Medication misadventures resulting in emergency department visits at an HMO medical center.

March 27, 2005

Application of emergency preparedness principles to a pharmacy department’s approach to a “black swan” event: the COVID-19 pandemic.

April 21, 2021

Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.

July 21, 2021

Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project.

January 25, 2023

Patient Safety Innovations

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

April 7, 2022

Standardization of compounded oral liquids for pediatric patients in Michigan.

August 31, 2016

Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.

July 21, 2021

Implementation of a discharge education program to improve transitions of care for patients at high risk of medication errors.

February 19, 2020

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017.

October 31, 2018

Reducing errors through discharge medication reconciliation by pharmacy services.

August 26, 2015

February 2, 2022

COVID-19: patient safety and quality improvement skills to deploy during the surge.

June 24, 2020

The patient died: what about involvement in the investigation process?

June 24, 2020

Is there a link between nursing home reported quality and COVID-19 cases? Evidence from California skilled nursing facilities.

August 12, 2020

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety.

December 9, 2020

Cancer diagnostic delay in Northern and Central Italy during the 2020 lockdown due to the coronavirus disease 2019 pandemic.

October 21, 2020

Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: a systematic review and meta-analysis.

August 4, 2021

The critical role of health information technology in the safe integration of behavioral health and primary care to improve patient care.

November 10, 2021

Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy.

July 29, 2020

Expanding frontiers of risk management: care safety in nursing home during COVID-19 pandemic.

September 30, 2020

Indication alerts to improve problem list documentation.

January 26, 2022

Human factors and ergonomics at time of crises: the Italian experience coping with COVID19.

July 22, 2020

A program to provide clinicians with feedback on their diagnostic performance in a learning health system.

October 28, 2020

Identifying psychiatric diagnostic errors with the Safer Dx Instrument.

September 30, 2020

A clinical pharmacist-led integrated approach for evaluation of medication errors among medical intensive care unit patients.

August 19, 2020

Factors influencing providers' willingness to deprescribe medications.

December 1, 2021

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

August 19, 2020

The use of anatomical side markers in general radiology: a systematic review of the current literature.

August 26, 2020

Absence or presence: silent discourse in the operating room and impact on surgical team action.

November 11, 2020

Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting.

March 3, 2021

Lessons from walking the medical distancing tightrope.

July 22, 2020

Managing teamwork in the face of pandemic: evidence-based tips.

June 24, 2020

Intervention study for the reduction of medication errors in elderly trauma patients.

September 2, 2020

Hospital medication errors: a cross sectional study.

December 23, 2020

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: a systematic review of randomized trials and non-randomized intervention studies.

August 18, 2021

Risk factors associated with medication ordering errors.

December 16, 2020

Alternatives to opioid education and a prescription drug monitoring program cumulatively decreased outpatient opioid prescriptions.

December 16, 2020

Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home: a qualitative descriptive study.

July 10, 2019

Analysis of lawsuits related to diagnostic errors from point-of-care ultrasound in internal medicine, paediatrics, family medicine and critical care in the USA.

June 24, 2020

Journal Article

Study

Patient Safety Innovations

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

April 7, 2022

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

July 29, 2020

Organizational characteristics and perceptions of clinical event notification services in healthcare settings: a study of health information exchange.

December 23, 2020

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children.

June 30, 2021

Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk.

November 11, 2020

Transitions from one electronic health record to another: challenges, pitfalls, and recommendations.

December 16, 2020

Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons from New York City.

July 29, 2020

RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.

August 17, 2022

Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review.

November 10, 2021

Omissions of care in nursing homes: a uniform definition for research and quality improvement.

November 18, 2020

A quality improvement initiative using peer audit and feedback to improve compliance with the surgical safety checklist.

July 27, 2022

Considering insulin pens for routine hospital use? Consider this...

May 28, 2008

Associations of physicians’ prescribing experience, work hours, and workload with prescription errors.

November 18, 2020

Nursing home staff turnover and perceived patient safety culture: results from a national survey.

November 4, 2020

Impact of a nationwide prospective drug utilization review program to improve prescribing safety of potentially inappropriate medications in older adults: an interrupted time series with segmented regression analysis.

November 4, 2020

Communication through the electronic health record: frequency and implications of free text orders.

July 29, 2020

Clinical and financial implications of second-opinion surgical pathology review.

April 7, 2021

Impact of pharmacist-led multidisciplinary medication review on the safety and medication cost of the elderly people living in a nursing home: a before-after study.

February 12, 2020

What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study.

May 26, 2021

Linking patient safety culture to quality ratings in the nursing home setting.

December 9, 2020

Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition to uptime.

April 27, 2022

Factors influencing family member perspectives on safety in the intensive care unit: a systematic review.

December 9, 2020

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.

November 11, 2020

Provider-patient communication and hospital ratings: perceived gaps and forward thinking about the effects of COVID-19.

December 16, 2020

From implementation to sustainment: a large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration.

August 18, 2021

Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates.

March 3, 2021

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

October 13, 2021

How accurately do older adult emergency department patients recall their medications?

August 12, 2020

A description of medical malpractice claims involving advanced practice providers.

July 15, 2020

Longitudinal medication reconciliation at hospital admission, discharge and post-discharge.

August 26, 2020

Patient safety and quality improvement: ethical principles for a regulatory approach to bias in healthcare machine learning.

July 22, 2020

Implementation of participatory organizational change in long term care to improve safety.

September 1, 2021

A machine learning-based clinical decision support system to identify prescriptions with a high risk of medication error.

October 21, 2020

Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home.

February 17, 2021

Beyond the corrective action hierarchy: a systems approach to organizational change.

August 26, 2020

The psychological experience of obstetric patients and health care workers after implementation of universal SARS-CoV-2 testing.

September 2, 2020

Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.

July 19, 2017

Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews.

July 8, 2020

August 19, 2020

Related Resources

Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system.

September 20, 2023

Handling polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals.

September 13, 2023

Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data.

August 30, 2023

Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action.

June 28, 2023

Patient safety perception within hospitals: an examination of job type, handoffs and information exchange, and hospital management support.

June 21, 2023

Challenge Competition: Impact of Patient Safety Tools.

June 14, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Uptake of pharmacist recommendations by patients after discharge: implementation study of a patient-centered medicines review service.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.

April 12, 2023

Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis.

March 8, 2023

The impact of medication reconciliation and review in patients using oral chemotherapy.

March 1, 2023

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

February 15, 2023

Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project.

January 25, 2023

Detectability of medication errors with a STOPP/START-based medication review in older people prior to a potentially preventable drug-related hospital admission.

December 21, 2022

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial.

November 30, 2022

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

Criteria for the selection of paediatric patients susceptible to reconciliation error.

November 16, 2022

Impact of medication reviews on potentially inappropriate medications and associated costs among older women in aged care.

September 21, 2022

Differences in medication reconciliation interventions between six hospitals: a mixed method study.

June 29, 2022

Standardized assessment of medication reconciliation in post-acute care.

April 27, 2022

Sources of medication omissions among hospitalized older adults with polypharmacy.

March 9, 2022

Medication errors' causes analysis in home care setting: a systematic review.

February 9, 2022

February 2, 2022

Quality standards for safe medication in nursing homes: development through a multistep approach including a Delphi consensus study.

October 27, 2021

Effect of medication reconciliation on patient reported potential adverse events after hospital discharge.

September 8, 2021

Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.

July 21, 2021

Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.

June 16, 2021

Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review.

June 9, 2021

Effects of pharmacist-conducted medication reconciliation at discharge on 30-day readmission rates of patients with chronic obstructive pulmonary disease.

June 9, 2021

See More About The Topic

Hospitals

Long-Term Care

Quality and Safety Professionals

Nursing

Discontinuities, Gaps, and Hand-Off Problems

Pharmacist-led program to improve transitions from acute care to skilled nursing facility care.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Pharmacist-led program to improve transitions from acute care to skilled nursing facility care.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site