Achieving safe medication management during transitions of care from hospital: time for a stewardship approach

Transitions of care from hospital have long been associated with a high risk of medication errors and adverse medication events. Preventing medication-related harm during transitions of care was a key action area in the World Health Organization’s third Global Patient Safety Challenge: Medication Without Harm, launched in 2017.¹ In 2020, the Australian Commission on Safety and Quality in Health Care (ACSQHC) published Australia’s response, which prioritised promoting and embedding medication reconciliation at transitions of care.¹ It also recommended:¹

• providing timely, accurate discharge summaries with standardised presentation
• utilising My Health Record to engage patients and carers in curation and communication of medication regimen information
• broad implementation of initiatives to reduce preventable medication-related readmissions for people with complex care needs, such as early post-discharge hospital outreach pharmacy or community liaison pharmacy services and cross-sector case conferencing
• refinement of risk criteria or indicators to direct interventions towards patients at the greatest risk of medication-related harm.

Progress in Australia has been mixed. Embedding and documenting medication reconciliation at hospital admission and discharge has advanced. However, discharge summaries continue to have inaccurate medication lists and inadequate explanation of medication changes.² Standardising the presentation of discharge summaries across different electronic medical record systems has proved challenging. My Health Record has improved clinicians’ access to patients’ medication regimens and associated information; however, patient engagement remains low, and, like any medication record, ongoing verification of data with the patient and other sources is required.³ Implementation of the ‘pharmacist shared medicines list’ (a verified medication history that can be uploaded to My Health Record) is a promising initiative, but awareness and uptake are limited.

Hospital outreach and community liaison pharmacist services, and cross-sector case conferencing, are uncommon. General practitioner–initiated pharmacist medication management reviews (Home Medicines Review and Residential Medication Management Review) are underused, and infrequently delivered early following a care transition.^4,5 In 2020, after decades of advocacy, Australia’s medication management review program was changed to allow hospital-based medical specialists to refer patients directly to credentialed pharmacists for a post-discharge review. Unfortunately, hospitals were not provided with resources for promotion, training or implementation, so uptake has been low and it has become evident that successful implementation relies on the resourcing of a dedicated transitions-of-care clinician or team.⁴ There has been progress in developing validated criteria to identify patients at risk of medication-related readmission,⁶ though more work is needed to ensure national generalisability and implementation.

Although not specifically addressed in Australia’s response to the Global Patient Safety Challenge, timely access to medicines, and the tools that are sometimes required to use them (e.g. medication administration charts, dose administration aids), is critical for reducing the risk of missed doses and medication errors after hospital discharge.⁷ Progress in this area has also been mixed. For example, reforms to enable medicines to be supplied by public hospitals using the Pharmaceutical Benefits Scheme, and implementation of interim medication administration charts for patients discharged to a residential care facility, have not occurred in all jurisdictions. Adoption of electronic medication charts in aged care has created new challenges in the delivery and use of interim charts because of the lack of interoperability of hospital and aged-care systems.

Responsibility and accountability for ensuring medication continuity and safety during transitions from hospital is not always clear. This is especially the case for complex, vulnerable patients when multiple health professionals, across multiple physical locations (e.g. hospital, general practice, community pharmacy, residential care facility), need to work together in a responsive and sequenced way to ensure medication delays and errors are avoided.^7-10

The ACSQHC recently published updated principles for safe and high-quality transitions of care.¹¹ They recommend a patient-centred approach with multidisciplinary collaboration, and highlight coordination of care by the patient’s general practice as a key enabler.¹¹ While general practice coordination of ongoing care is vital, it is not realistic for a general practice to coordinate time-critical aspects of medication management for complex hospital discharges, which occur 7 days a week at any time of day.^4,7,10 There needs to also be coordination from the hospital, in collaboration with the patient and their carer, the general practice, community pharmacy and other providers such as residential care staff, to bridge the gap and ensure safe, high-quality medication management following discharge.

The National Safety and Quality Health Service Standards for hospitals address transitions of care in a number of standards (e.g. Partnering with Consumers, Medication Safety, Communicating for Safety), but the absence of an overarching framework for medication safety across the care continuum means there may be a lack of coordination and accountability. Hospitals may establish governance committees, policies and guidelines for individual standards, without specific oversight and coordinated cross-discipline and cross-sector policies and procedures for medication management during care transitions.

A transitions-of-care medication stewardship approach, modelled on existing successful stewardship programs (e.g. antimicrobial stewardship), offers a potential solution to the intractable problem of medication-related harm following hospital discharge.^4,12 Stewardship programs take a strategic approach to implementing governance, interventions and tools that reduce variations in practice, ensure safe use of medicines and efficient use of resources, and improve health outcomes.¹² Hospital-based transitions-of-care medication stewardship programs could provide clarity around responsibility and accountability, improve planning and coordination of medication management, and provide education and support to hospital- and community-based clinicians, to overcome the many barriers that contribute to medication delays, miscommunication, medication errors and delayed medication review following care transitions.

In 2023 the ACSQHC commissioned the authors of this editorial to conduct a literature review and environmental scan to identify existing stewardship frameworks and strategies targeting medication management at transitions of care. No comprehensive stewardship frameworks were identified. Therefore, the ACSQHC is leading the development of a stewardship framework for medication management at transitions of care that will provide hospitals with a systematic approach to optimise safety and quality at care transitions.

To be successful, a stewardship program would require institutional support, a governance framework with cross-sector and consumer representation,¹³ local policies and procedures, quality standards and indicators, and a multidisciplinary stewardship team responsible for planning, supporting and coordinating activities and interventions, such as those listed in Box 1.^1,7,11,13-21

Applying a stewardship framework with strong governance, multidisciplinary leadership and clear accountabilities has the potential to generate a much-needed step-change in medication safety during transitions of care.

Conflicts of interest: The authors acknowledge the Australian Commission on Safety and Quality in Health Care (ACSQHC) for funding a literature review and environmental scan on frameworks and strategies targeting medication management at transitions of care.

Manya Angley, Deirdre Criddle, Rohan Elliott and Jonathan Penm are co-investigators on a Medical Research Future Fund (MRFF) project ‘Timely post-discharge medication reviews in rural and regional Australia’. MRFF is funded by the Australian Government.

Deirdre Criddle is also an investigator on an MRFF project ‘Older persons early recognition access and treatment in emergencies’.

Rohan Elliott is an editor for Australian Prescriber. He was excluded from editorial decision-making related to the acceptance and publication of this editorial.

Fatemeh Emadi and Shania Liu have no conflicts of interest to declare.

This article is peer reviewed.

 

References

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