Improving medication safety through transitions of care


Patricia Kienle, RPh, MPA, FASHP

Accreditation and Medication Safety
Innovative Delivery Solutions
Cardinal Health

Pat Uselton, RPh

Pharmacy Operations, Quality and Pharmacy Practice
Innovative Delivery Solutions
Cardinal Health

Patient care involves transitions between many healthcare providers and different environments.

These hand-offs are a precarious time for medication management – moments when errors and misunderstandings can occur.

How can a pharmacist make sure that patient safety is sustained during these transitions in patient care?

Cardinal Health expert Patricia Kienle moderated an important panel at the 2013 ASHP Midyear Clinical Meeting, entitled: "Transitions of Care: Your Role in Medication Safety. " Panel members provided an overview of the issue and shared real-world best practices and case studies showing how transitions can be improved.

Here, two leading medication management experts at Cardinal Health Innovative Delivery Solutions: Patricia Kienle and John "Pat" Uselton, discuss this very important topic.

Q: Why is it so important to understand best practices for improving medication safety during transitions of care?

Kienle: We recognize today that there are points in the healthcare system when the potential for error increases. Whenever a patient passes from one clinician to another or between facilities, a transition occurs and deserves special attention. For a hospital pharmacist, the key transition is usually the patient's discharge from the hospital to the community.

Uselton: In the past, the focus has been on transitions within a facility. Now hospital pharmacists have to think well beyond this - to understand and implement best practices for respiratory therapy, physical therapy, outpatient prescriptions and so on.

Q: Why are the transitions so tricky?

Uselton: You've got more people involved and not everyone is under the same roof. You not only have other professions - physicians, therapists, etc. - who need to coordinate, but you often have multiple pharmacists - a hospital pharmacist, a community pharmacist, a consultant pharmacist for long-term care patients - involved with the same patient.

Kienle: In addition, many patients use more than one community pharmacist. They may get antibiotics from the grocery store pharmacy, something else at an independent pharmacy. There's no obvious and easy way to coordinate of the process.

Q: Any suggestions on how to manage medication across these transitions?

Kienle: Someone needs to shepherd the whole thing through. We can't stay within our professional silos anymore. Medication Therapy Management (MTM) is one way to go. It's been around for a while, mostly in the background. Under MTM, one pharmacist might manage a patient's medications from multiple physicians. The pharmacist becomes the point person -- to answer the patient's questions or even make recommendations to physicians on how to tailor the therapy to a patient.

Q: What's key about the first transition - admission to the hospital?

Uselton: Reconciliation. The most important medication reconciliation is the one done when a patient enters the hospital. It all starts with best practices that target reconciliation - getting an accurate list of everything a patient is taking.

Q: How does that differ from the discharge transition?

Kienle: Discharge is all about compliance - getting the patient to take medicine correctly at home. The problem is: who's responsible for compliance? A patient may be well at discharge, but then it's pretty much up to him to manage his medicines. A hospital pharmacist needs to be good at identifying issues that may come up after discharge and being a great educator to help the patient avoid problems.

Q: Can you give an example?

Kienle: It may be as simple as anticipating the question: "What if I miss a dose?" Help the patient understand which side effects are OK and which ones are serious warning signs. Let him know what it means if his ankles swell. Let the patient know when it's right to call a pharmacist or a physician.

Q: What role do patients play?

Uselton: Patients absolutely must take responsibility for their own care. They're in the best position to make transitions go smoothly. The Affordable Care Act (ACA) wants everyone to be on electronic health records. Hospitals have incentives to move this way, but we're not there yet.

Q: What can technology do for patients today?

Uselton: We have apps for hand-held devices to help patients better manage medication. Of course that will work better for a young person taking anti-coagulants after orthopedic surgery than an 80-year-old patient who may not be comfortable with the technology.

Q: Do transition challenges affect healthcare costs?

Kienle: Avoiding readmissions are huge for patient safety and from a financial standpoint for healthcare systems. Under ACA, hospitals pay a financial price when readmissions are unnecessarily high. You never want someone back in the hospital because of medication compliance problems