Post-Discharge Telephone Intervention with a Clinical Pharmacy Specialist for Gastrointestinal Medical Oncology Patients

Background: Oncology patients are a vulnerable population with medication-related problems spanning across care settings. Gastrointestinal medical oncology (GIMO) patients often have unique medication challenges due to extensive treatment history. High-quality medication reconciliation aids in preventing medication discrepancies and potential adverse events during transitions of care. We conducted a pilot post-hospital discharge intervention with clinical pharmacy specialists for GIMO patients. Objective: The primary objective was to identify the frequency of medication discrepancies. Methods: GIMO patients discharged from our hospital were identified and called within 7 days of discharge. Clinical pharmacy specialist telephone encounters occurred between December 2021 and February 2022. Results: A total of 100 patients were included. The median age was 64 years, and the median time for the telephone call was approximately 30 minutes. At least one medication discrepancy was identified in 41% of telephone calls. Reasons for discrepancies included patients taking medications not as prescribed or not prescribed at all, continuing medications that were discontinued, duplicating therapy, or not taking prescribed medications until visiting their outpatient primary team. Safety events due to hospital discharge errors were reported in 14% of cases, including duplicate therapy prescribed, missing or incorrect prescription information, or counseling not reinforced. Discussion: Our telephone intervention quickly resolved medication-related issues and provided additional education for patients. High-quality, step-by-step medication review is needed following hospitalizations to reduce medication safety events in GIMO patients.