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Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.
Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;31:609-622.
Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.
Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18:3925.
Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.
Haydar B, Baetzel A, Stewart M, et al. Anesth Analg. 2020;131:245-254.
Children undergoing intrahospital transport are at risk for adverse events. This study used perioperative adverse event data reported to a patient safety organization to identify pediatric anesthesia transport-associated adverse events. A small proportion (5%) of pediatric anesthesia adverse events were associated with transport, but the majority of events were deemed preventable and one-third resulted in patient harm. Cardiac arrest and respiratory events occurred most frequently and largely affected very young children (<6 month). A previous WebM&M discussed a perioperative respiratory event in a pediatric patient during intrahospital transport.
Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. J Eval Clin Pract. 2021;27:160-166.
Researchers analyzed medication errors occurring in the trauma service of a single university hospital in Spain to inform the development and implementation of a set of measures to improve the safety of the pharmacotherapeutic process. The Multidisciplinary Hospital Safety Group proposed improvement measures that intend to involve pharmacists in medication reconciliation, increase the use of medication reconciliation in the emergency and trauma departments, and incorporate protocols and alerts into the electronic prescribing system.
Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Res Social Adm Pharm. 2020;17:677-684.
This study explored the impact of longitudinal medication reconciliation performed at transitions (admission, discharge, five-days post-discharge). Medication changes implemented due to longitudinal reconciliation prevented harm in 82% of patients. Potentially serious errors were frequently identified at hospital discharge and commonly involved antithrombotic medications.
Stolldorf DP, Mixon AS, Auerbach AD, et al. Am J Health Syst Pharm. 2020;77:1135-1143.
This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).
Achilleos M, McEwen J, Hoesly M, et al. Am J Health Syst Pharm. 2020;77.
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. 
Herledan C, Baudouin A, Larbre V, et al. Support Care Cancer. 2020;28:3557-3569.
This systematic review synthesizes the evidence from 14 studies on medication reconciliation in cancer patients. While the majority of studies did not include a contemporaneous comparison group, they did report that medication reconciliation led to medication error identification (most frequently drug omissions, additions or dosage errors) in up to 88-95% of patients.
Discharge planning is an essential part of transitions of care, during which patients are often at a higher risk for adverse events and harm. It is important for all healthcare providers to identify risk factors prior to transitioning patients and put plans in place as part of the discharge plan to mitigate harm. Effective discharge planning between the discharging and accepting healthcare teams can help reduce adverse events.
Bloodworth LS, Malinowski SS, Lirette ST, et al. Journal of the American Pharmacists Association: JAPhA. 2019;59:896-904.
Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.  
Following catheter-guided thrombolysis for a large saddle pulmonary embolism, a man was monitored in the intensive care unit. The catheters were removed the next day, and the patient was sent from the interventional radiology suite to the postanesthesia care unit, after which he was transferred to a telemetry bed on the stepdown unit. No explicit plan for anticoagulation was discussed with the accepting medical team. Shortly after the nurse found the patient lethargic, tachycardic, and hypoxic, the patient lost his pulse and a code was called.
Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.
Craynon R, Hager DR, Reed M, et al. Am J Health Syst Pharm. 2018;75:1486-1492.
Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.
Pellegrin K, Lozano A, Miyamura J, et al. BMJ Qual Saf. 2019;28:103-110.
Older adults frequently encounter medication-related harm, which may result in preventable hospitalizations. In six Hawaiian hospitals, hospital pharmacists identified older patients at risk of medication problems and assigned them to a community pharmacist who coordinated their medications across prescribers for 1 year after discharge. This post-hoc analysis of the intervention found that most medication-related harm occurred in the community (70%) rather than the hospital and that the intervention successfully reduced community-acquired harm.
Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization.
Polinski JM, Moore JM, Kyrychenko P, et al. Health Aff (Millwood). 2016;35:1222-9.
This intervention study provided pharmacist support to perform medication reconciliation and care coordination for patients discharged from the hospital. Compared to similar-risk patients who did not receive the intervention, those who had medication reconciliation by pharmacists were less likely to be readmitted to the hospital. These results add to the existing literature supporting the utility of pharmacist-led care transition interventions.
Ensing HT, Koster ES, Stuijt CCM, et al. Int J Clin Pharm. 2015;37:430-4.
Patients are susceptible to various problems following hospital discharge, including medication errors. This commentary suggests that improving the transfer of patient medication history, performing home visits to follow up with patients, and collaboration between primary care and community pharmacy can help reduce adverse drug events after patients are discharged from the hospital.
O'Leary KJ, Turner J, Christensen N, et al. J Hosp Med. 2015;10:147-51.
Clinician discontinuity is often cited as a potential patient safety issue. However, this study found that transfers of care between hospitalists did not appear to be associated with adverse events. The authors note that as hospital care is provided within teams, research should focus on the effects of team complexity and changes on patient safety.