The incidence of medication errors on discharge prescriptions following pharmacist discharge prescription planning (PDPP) in an orthopaedic surgery unit: a parallel group-controlled study

Pharmacist Discharge Prescription Planning (PDPP) supports safe and effective transition of patients from hospital to home or other care settings. It involves a pharmacist reviewing and reconciling the patient's medications and planning an accurate discharge prescription. Orthopaedic patients are particularly susceptible to medication-related errors at discharge due to several factors including polypharmacy and frequent prescribing of high-risk medications. Previous PDPP studies have not focused on orthopaedic patients exclusively. To assess the impact of PDPP on medication errors on the discharge prescriptions of orthopaedic patients from an Australian tertiary metropolitan hospital. This was a prospective, parallel-group control study, conducted between July 2024 to October 2024. The control group received standard care with doctors writing the prescription followed by pharmacist review and reconciliation. The intervention group involved the pharmacist preparing the discharge prescriptions which were reviewed and co-signed by the doctor. Data was collected on patient demographics, number of medications on prescriptions, number of errors and types of errors. Data was analysed on JASP (Version 0.19.3). The intervention group consisted of 31 patients, while the control group included 23 patients. A total of 3 medication errors were observed across 224 medications prescribed in the intervention group, compared to 23 errors for 79 medications in the control group. Prescriptions with at least one medication error were lower for the intervention group (9.7% vs 56.5%, p < 0.001). The rate of error per medication reduced from 29.1% in the control group to 1.3% in the intervention group ( p < 0.001). The relative risk reduction for the intervention was 95.4% (p < 0.001, 95% CI 85.1%-98.6%). Of the 23 errors identified in the control group, the most prevalent were incorrect quantity (n = 6), followed by omissions (n = 5) and contraindications (n = 3). PDPP significantly reduces medication errors on discharge prescriptions for orthopaedic patients. Future studies are encouraged to investigate the impact on patient flow.