Pharmacist-led Transitions of Care: A Cohort Study on Admission Medication History Factors and Adjustments to the Discharge Medication List

<b>Background:</b>Patients are at risk of experiencing medication errors during each transition of care (TOC), which can result in adverse drug events and readmissions. Implementing a pharmacist-led TOC service can optimize medication safety and patient outcomes by identifying and correcting medication discrepancies prior to hospital discharge. A pharmacist-led TOC service at a tertiary care center expanded services to review medications at discharge for all enrolled hospitalized patients, but data collection and review had yet to be performed. <b>Objective:</b> The purpose of this study was to evaluate the number of patients with a medication discrepancy identified at hospital discharge in a pharmacist-led TOC service. <b>Methods:</b> This was a single center, retrospective cohort study conducted at a tertiary care facility. Admission medication histories were completed by pharmacists in the emergency department and inpatient units. TOC discharge medication reconciliations were completed by pharmacists prior to hospital discharge. The study included hospitalized adult patients with a pharmacist-completed admission medication history and discharge medication reconciliation between July 1, 2021, to September 30, 2021. Patients readmitted within the study period were included more than once if study criteria were met. Patients who left against medical advice, discharged to hospice, or expired were excluded from the study. <b>Results:</b> A total of 213 patients met inclusion criteria for this study, with 214 patient encounters included in the analysis after accounting for readmissions. More patients had a TOC medication discrepancy identified at discharge when admission medication histories were completed less than or equal to 24 hours after hospital admission versus greater than 24 hours after hospital admission (28.2% vs 23.6%, OR: 1.269, 95% CI: 0.658, 2.448). Fewer patients had a TOC discrepancy at discharge when fewer PTA medications were changed versus more PTA medications were changed during the admission medication history (0-1 medication changes vs ≥10 medication changes: 19% vs 29.4%, OR: 1.780, 95% CI: 0.730, 4.339). Fewer patients had a TOC discrepancy at discharge when admission medication histories were completed in the emergency department versus on the inpatient units (22.4% vs 28.6%, OR: 0.721, 95% CI: 0.366, 1.420). A similar number of patients had a TOC discrepancy at discharge regardless of the number of unit transitions throughout their hospital stay (1-2 transitions vs ≥4 transitions: 25.9% vs 25.5%, OR: 0.977, 95% CI: 0.456, 2.096). <b>Conclusions:</b> One in four patients enrolled in the pharmacist-led TOC service had a medication discrepancy identified at discharge. This was irrespective of when the admission medication history was completed, how many changes were made, or how many times the patient transitioned units. Therefore, medication reconciliation at discharge should be a service provided to all admitted patients.