Pharmacist discharge summary: Impact of inpatient to community pharmacist handoff at hospital discharge.

BACKGROUND

Community pharmacists are often the initial health professionals whom patients encounter after hospital discharge but are rarely provided relevant discharge information.

OBJECTIVES

Implement a pharmacist-to-pharmacist discharge summary (P2PDS) to improve the safety of pharmacist care provision to patients transitioning home from the hospital.

PRACTICE DESCRIPTION

Inpatient pharmacists at an academic medical center conduct discharge medication reconciliation and release discharge electronic prescriptions to dispensing pharmacies.

PRACTICE INNOVATION

A multidisciplinary intersystem quality improvement project was conducted to demonstrate the impact of clinical information sharing via the P2PDS to community pharmacists.

EVALUATION METHODS

With input from community pharmacists, the P2PDS was created and implemented on inpatient units throughout the health system. Outcomes assessed included identification of medication discrepancies, enrollment into reimbursable medication management services, and pharmacist confidence when filling discharge prescriptions.

RESULTS

During the study period, community pharmacists identified a total of 388 medication discrepancies in 161 patients; 16% of discrepancies were considered "unintentional." Twenty-five discharging patients were identified for enrollment in medication management services, with 20 of these patients enrolling in all 3 services (medication delivery, synchronization, and medication packaging). The P2PDS increased community pharmacist confidence in discharge medication filling (40% vs. 95%, P < 0.001) and increased the percent of patients receiving community pharmacist medication reconciliation (14%-76%, P < 0.001).

CONCLUSION

Enhancing pharmacist communication across practice settings with a P2PDS decreases care fragmentation through identification of medication discrepancies and improves pharmacist confidence in patient care provision.