1. Rosalynn L. Pangan
Public Relations Officer
The Philippine Society of Hospital Pharmacists
St. Luke’s Medical Center – Global City

2. WHAT IS TRANSITION OF CARE?
“care transitions" refers to
the movement patients make
between health care
practitioners
http://www.caretransitions.org/definitions.asp

3. WHAT IS TRANSITION OF CARE?
 Transitional care is defined as a set of
actions designed to ensure the coordination
and continuity of health care as patients
transfer between different locations or
different levels of care within the same
location.
 Representative locations include (but are not
limited to) hospitals, sub-acute and post-acute
nursing facilities, the patient's home, primary
and specialty care offices, and long-term care
facilities.
Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee.
Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American
Geriatrics Society. 2003;51(4):556-557.)

4. MEDICATION ERRORS IN
TRANSITIONS OF CARE

5. MEDICATION ERRORS IN
TRANSITIONS OF CARE
 Study Design: Prospective
 Results:
 After screening 523 admissions, 151 patients were enrolled
based on the inclusion criteria
 81patients (53.6%; 95% confidence interval, 45.7%-61.6%)
had at least 1 unintended discrepancy.
 Most common error (46.4%) was omission of a regularly
used medication.
 61.4% of the discrepancies were judged to have no potential
to cause serious harm.
 38.6% of the discrepancies had the potential to cause
moderate to severe discomfort or clinical
deterioration.
Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med2005;165(4):424-9.

6. MEDICATION ERRORS IN
TRANSITIONS OF CARE
 Study Design: Population-based cohort study using admin
records from 2007 to 2009 of hospitalizations and
outpatient prescriptions
 Results:
 Patients admitted to the hospital (n = 187,912) were more
likely to experience potentially unintentional discontinuation of
medications than controls (n = 208,468) across all medication
groups examined.
 Admission to an ICU was associated with an additional risk of
medication discontinuation in 4 of 5 medication groups vs
hospitalizations without an ICU admission.
 One-year follow-up of patients who discontinued medications
showed an elevated AOR for the secondary composite outcome
of death, emergency department visit, or emergent
hospitalization of 1.07 (95% CI, 1.03-1.11) in the statins group
and of 1.10 (95% CI, 1.03-1.16) in the
antiplatelet/anticoagulant agents group.
 Patients prescribed chronic medications were at higher risk for
unintentional discontinuation following hospital discharge, and
ICU stay during hospitalization increased the risk of
medication discontinuation even further
. Bell CM, Brener SS, Gunrai N, et al. Association of ICU or hospital admission with unintentional
discontinuation of medications for chronic diseases. JAMA 2011;306(8):840-7.

7. MEDICATION ERRORS IN
TRANSITIONS OF CARE
 StudyDesign: Prospective
 Method:
 60 randomly selected patients at a Canadian Community
hospital
 At admission, compared patients’ medication ordesr with
pre-admission medication use based on med vials and
interviews with patients, caregivers and/or outpatient
healthcare providers
 At discharge, pre-admission and in-patient medications
were compared with discharge orders and written
instruction
 Variances were discussed with prescriber and classified
either as intended or unintended
Vira T., Colquhoun, M., Etchells, E. Reconcilable differences: correcting medication errors at
hospital admission and discharge. Qual Saf Health Care. 2006 April; 15(2): 122–126.

8. MEDICATION ERRORS IN
TRANSITIONS OF CARE
 Results:
 Overall, 60% (95% CI 48 to 72) of patients had at
least one unintended variance and 18% (95% CI 9 to
28) had at least one clinically important unintended
variance.
 None of the variances had been detected by usual
clinical practice before reconciliation was conducted.
 Of the 20 clinically important variances, 75% (95% CI
56 to 94) were intercepted by medication
reconciliation before patients were harmed.
Vira T., Colquhoun, M., Etchells, E. Reconcilable differences: correcting medication errors at
hospital admission and discharge. Qual Saf Health Care. 2006 April; 15(2): 122–126.

9. MEDICATION ERRORS IN
TRANSITIONS OF CARE
Vira T., Colquhoun, M., Etchells, E. Reconcilable differences: correcting medication errors at
hospital admission and discharge. Qual Saf Health Care. 2006 April; 15(2): 122–126.

10. MEDICATION ERRORS IN
TRANSITIONS OF CARE
 Study Design: Prospective
 Method: studied patients who were consecutively discharged
home or to a seniors' residence from the general internal
medicine service during a 14-week interval in 2002; phone
interview and chart review to identify outcomes; 2 physicians
conducted an independent review the outcomes to determine
occurrence of AE
 Results:
 outcomes were determined for 328 of the 361 eligible patients, who
averaged 71 years of age
 After discharge, 76 of the 328 patients experienced at least 1 AE
(overall incidence 23%, 95% confidence interval [CI] 19%–28%).
 AE severity ranged from symptoms only (68% of the AEs) or symptoms
associated with a nonpermanent disability (25%) to permanent
disability (3%) or death (3%).
 Most common AEs were adverse drug events (72%), therapeutic errors
(16%) and nosocomial infections (11%). Of the 76 patients, 38 had an
AE that was either preventable or ameliorable (overall incidence 12%,
95% CI 9%–16%).
Forster A J, Clark H D, Menard A. et al Adverse events among medical patients after discharge from
hospital. Can Med Assoc J 2004. 170345–349.349.

11. MEDICATION ERRORS IN
TRANSITIONS OF CARE

12. WHAT IS THE KEY ROLE OF
HOSPITAL PHARMACISTS IN
TRANSITIONS OF CARE?

13. WHAT IS MEDICATION
RECONCILIATION
 “theprocess of creating the most
accurate list possible of all
medications a patient is taking —
including drug name, dosage,
frequency, and route — and
comparing that list against the
physician’s admission, transfer, and/or
discharge orders, with the goal of
providing correct medication to the
patient at all transition points within the

14. IMPACT OF HOSPITAL
PHARMACISTS IN
TRANSITIONS OF CARE

15. IMPACT OF MEDICATION
RECONCILIATION DURING
ADMISSION
 Study Method: Study pharmacist and hospital-
physician medication histories were compared with
medication orders to identify unexplained history
and order discrepancies in 651 adult medicine
service inpatients with 5,701 prescription
medications
 Results:
 35.9% experienced 309 order errors
 85% of patients had errors originate in medication histories,
and almost half were omissions.
 Cardiovascular agents were commonly in error (29.1%). If
undetected, 52.4% of order errors were rated as potentially
requiring increased monitoring or intervention to preclude
harm; 11.7% were rated as potentially harmful.
 In logistic regression analysis, patient's age > or = 65 [odds
ratio (OR), 2.17; 95% confidence interval (CI), 1.09-4.30] and
number of prescription medications (OR, 1.21; 95% CI, 1.14-
1.29) were significantly associated with errors potentially
requiring monitoring or causing harm.
 Presenting a medication list (OR, 0.35; 95% CI, 0.19-0.63) or
bottles (OR, 0.55; 95% CI, 0.27-1.10) at admission was
beneficial.
Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications At Transitions and Clinical Handoffs (MATCH)
Study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med 2010;25(5):441-7.

16. PHARMACIST FACILITATED
DISCHARGE
 Study Design: Descriptive Report
 Methods:
 Clinical pharmacist participated in multidisciplinary
discharge rounds in selected medicine services
 Patient selection: (1) discharge to home, (2) with >5
medications with at least 1 high risk medicine; (3)
English speaking; (4) active telephone service
 CP activities: (1) reconciled with clinicians discharge
medication discrepancies; (2) counseled patients and
families; (3) provided reconciled medication list to
subsequent providers; (4) contacted patients within
72 hours after discharge and at 30 days to identify
and address post-discharge medication problems.
Walker, P.C. et. al. Pharmacist facilitated discharge: a prospective study of medication reconciliation and
telephone . 2007

17. PHARMACIST FACILITATED
DISCHARGE
 Results (10-month period):
 958 out 1122 patients (85%) were screened
 721 (75%) patients met the inclusion criteria
 477 (66.2%) patients were interviewed to assess current
medication use
 248 (34%) patients were counseled at discharge
 486 discrepancies identified and resolved in 63% of
patients counseled with an average of 3 discrepancies
per patient
 Missing Meds (41.2%)
 Failure to Discontinue unnecessary or inactive meds (23.7%)
 Wrong dose/frequency (16.3%)
 Discrepancy occurred most frequently in the following
therapeutic classes: CV, analgesic, endocrine, antimicrobial
and gastric acid suppression
 Follow-up phone call within 72 hrs. and at 30 days are
completed in 24% (59) and 8.5%(21), respectively.
 123 post-discharge problems were identified and resolved
Walker, P.C. et. al. Pharmacist facilitated discharge: a prospective study of medication reconciliation and
telephone . 2007

18. KEY ELEMENTS TO
SUCCESSFUL MEDICATION
RECONCILIATION

19. “ONE SOURCE OF TRUTH”
 Develop a single
medication list,
shared by all
disciplines for
documenting the
patient's current
medications.
Source: Medications at Transitions and
Clinical Handoffs (MATCH) Toolkit for
Medication Reconciliation.
http://www.ahrq.gov/qual/match/match1.
htm
http://www.ashp.org/s_ashp/docs/files/Me
dRec_3414AHome.pdf

20. DEFINE ROLES
 Clearly define roles and responsibilities for each discipline involved in
medication reconciliation.
 To help determine roles and responsibilities, map out the various
admission points in your organization
Source: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for
Medication Reconciliation. http://www.ahrq.gov/qual/match/match1.htm

21. SAMPLE WORKSHEET
Source: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.
http://www.ahrq.gov/qual/match/match1.htm

22. INTEGRATE MEDICATION
RECONCILITATION INTO EXISTING
WORKFLOW
 Standardize and simplify the medication reconciliation
process
 Eliminate unnecessary redundancies
 Make the right thing to do the easiest thing to do within the
patterns of normal practice.
 Ensure process design meets all pertinent local laws or
regulatory requirements.
 Linking medication reconciliation to other strategic goals
(e.g., heart failure publicly reported process of care
measures related to discharge instructions on medications)
and/or other initiatives (e.g., a hospital project working on
improving patient satisfaction related to pain management
or patient communication regarding medications) when
appropriate can also strengthen the importance of this
process.
Source: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.
http://www.ahrq.gov/qual/match/match1.htm

23. SAMPLE WORKSHEET
http://www.ashp.org/s_ashp/docs/files/PS_Flowcharts%20of%20MedRec%20for%20Ambulatory%20Settings.pdf

24. EDUCATE PATIENTS
 Educate
patients and
their families
or caregivers
on medication
reconciliation
and the
important role
they play in
the process.
Source: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.
http://www.ahrq.gov/qual/match/match1.htm

25. WHERE CAN MEDICATION
RECONCILIATION HAPPEN?

26. WHERE CAN MEDICATION
RECONCILIATION HAPPEN?
Admission
 Medication History
 Verification is an important step, as patients often forget to mention
medications or OTC medications/herbal supplements during the initial
medication collection. Any new information regarding the patient's
home medication list should be discussed with the physician and
resulting changes documented
 provides an educational opportunity to teach patients about the medications
ordered for them in the hospital in relation to their home medications, and
comment on any differences.
 Reconciling home medications with current inpatient orders.
 Clarifying unintended discrepancies (i.e., discrepancies that
are not explained by the current care plan, by the patient's
clinical status, or formulary substitution) with the physician
for resolution.
 Completing a discipline-specific form with radio buttons and
comment sections to document interactions and clarifications
with patients, other sources, and the prescriber to trace follow-
through on discrepancies and resulting clarifications and
modifications, if needed
Source: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for
Medication Reconciliation. http://www.ahrq.gov/qual/match/match1.htm

27. WHERE CAN MEDICATION
RECONCILIATION HAPPEN?
 Intra-hospital Transfer
Assess current medication orders and
make any changes or modifications in
preparation for the new level of care.
Review the patient's pre-admission
medication list. Home medications
initially held may now be appropriate to
restart upon transfer.
Source: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for
Medication Reconciliation. http://www.ahrq.gov/qual/match/match1.htm

28. WHERE CAN MEDICATION
RECONCILIATION HAPPEN?
 Discharge
 Contact the physician if the patient's discharge
medication list is not updated and/or complete (note:
when establishing roles and responsibilities for
preparing patients' discharge medication lists, a
blanket statement such as "resume home
medications" is not acceptable).
 Contact the physician to clarify patient questions
encountered during the patient counseling session
prior to discharge.
Source: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for
Medication Reconciliation. http://www.ahrq.gov/qual/match/match1.htm

29. WHERE CAN MEDICATION
RECONCILIATION HAPPEN?
 External Transfers
Patient's list of medications prior to
their hospitalization.
Medications that are being
administered to the patient at the
outside hospital prior to transfer.
Medications ordered at your hospital.

30. TAKE HOME MESSAGE

31. DOWNLOADABLE
RESOURCES/TOOLS
1. http://www.ahrq.gov/qual/match/
2. http://www.ashp.org/menu/PracticePolicy/Resou
rceCenters/PatientSafety/ASHPMedicationReco
nciliationToolkit_1/MedicationReconciliationBa
sics.aspx
3. http://www.ihi.org/offerings/MembershipsNetwo
rks/MentorHospitalRegistry/Pages/MedicationR
econciliationADE.aspx

32. TRANSITIONS OF CARE
ROLE OF HOSPITAL PHARMACISTS IN
Rosalynn L. Pangan
Public Relations Officer
The Philippine Society of
Hospital Pharmacists
St. Luke’s Medical Center –
Global City