Hospital pharmacist interventions to correct medication errors on discharge prescriptions: a prospective observational study

Abstract At hospital discharge, many patients receive multiple, complex prescriptions, prepared by junior medical staff. Most Australian hospitals have pharmacists review discharge prescriptions to correct errors before they are dispensed or provided to patients. This prospective, observational study quantified the prevalence and types of hospital pharmacist interventions on discharge prescriptions at a tertiary referral metropolitan health service, located in Victoria, Australia. It included consecutive patients discharged on weekdays with a prescription from a general medicine, surgical, or oncology/haematology unit. Data were extracted from prescriptions, electronic medical records, and daily discussions with ward pharmacists. The primary endpoint was the proportion of patients whose discharge prescriptions required pharmacist intervention. The 300 patients included were prescribed a median (interquartile range) of 8 (5–11) regular discharge medications. Overall, 199 (66.3%, 95% confidence interval 60.6–71.6%) patients required a total of 477 pharmacist interventions with no significant differences between clinical areas. The predominant intervention types were the removal of unnecessary medications ( n = 93, 19.5%), the addition of omitted medications ( n = 85, 17.8%), and correction of wrong directions ( n = 81, 17.0%). The Australian Digital Health Agency intends to implement electronic hospital discharge prescriptions using electronic tokens (e‐tokens). In the community, e‐tokens are sent directly from prescribers to patients or their community pharmacy. If discharge prescriptions were to bypass hospital pharmacist review, some errors would be difficult for community pharmacists to detect and easily resolve without access to hospital records and medical teams and some medications require specialised expertise. Therefore, the integration of hospital pharmacist review into electronic discharge workflows is imperative to ensure medication safety prior to e‐token transmission. Ethical approval was granted by the Austin Health Human Research and Ethics Committee (Reference no: HREC/107485/Austin‐2024) and the study conforms with the Australian National statement on ethical conduct in human research .