Continuity of care and reducing risk during transitions of care

Introduction

The World Health Organization (WHO) defines transitions of care (ToC) as the various points where a patient moves to, or returns from, a particular physical location or makes contact with a healthcare professional for the purposes of receiving healthcare. This includes transitions between home, hospital, residential care settings and consultations with different healthcare providers in outpatient facilities^​1​. The term ‘ToC’ encompasses the clinical aspects of care transfer and other factors, such as the preferences, experiences and needs of the patient.

ToC, including when patient movement occurs between wards in a hospital setting, is a recognised risk factor for medication-related harm^​2–4​. When people move between care settings, their medication is often subject to change and these changes are not always clear to the patient, especially at discharge^​5,6​. Patients may feel overwhelmed or confused by medication changes that have occurred during hospitalisation, and any discharge counselling they receive about their medication may not be fully understood because patients are often distracted, overloaded with information and eager to leave for home^​7​. The patient’s primary healthcare provider may not be advised about changes to medication that have been made^​8​. Such discontinuity of care and poor communication at hospital discharge can result in medication-related problems, adverse events and even readmissions^​9,10​.  

One 2021 study from the Netherlands found that 16% of readmissions are medication-related, of which 40% are potentially preventable^​11​. Most of the medication errors involved in the potentially preventable readmissions were classified as non-adherence (35%) and prescribing errors (35%), followed by transition errors (30%). A UK study reported in 2018 that the incidence of hospital readmission associated with medication-related harm in older adults was 78 per 1,000 discharges^​10​. This study estimated the cost to the NHS of post-discharge medication harm in older adults at £396m, of which over 90% is attributable to hospital readmissions^​10​.

Guidance from the National Institute for Health and Care Excellence^​12​, referencing a 2012 Royal Pharmaceutical Society (RPS) document^​13​, noted that between 30% and 70% of patients have an error or unintentional change to their medicines when moving from one care setting to another. More recently, in 2020, a systematic review estimated that up to half of adults discharged from the hospital to the community experience at least one medication error or unintentional medication discrepancy, and one out of five adults discharged suffer an adverse drug event^​14​. A modelling study examining how the digital transfer of a patient’s prescription information would affect patient safety estimated that, in England, a single digital prescribing record could reduce medication errors by between 10% and 50%, leading to between 18,000 and 913,000 fewer errors, and saving 4 to 22 lives annually^​15​. Many studies have shown that problems at ToC involve reconciliation errors^​16​, patient confusion^​5​,  inappropriate continuation of short-term medication^​17​ and inadequate monitoring^​18​.

This article will consider the work being done to reduce medicines related harm at ToC, the role of pharmacy teams and some considerations for pharmacy teams to integrate into their practice.

World Health Organization initiative

The WHO’s Global Patient Safety Challenge: Medication Without Harm, launched in 2017, focuses on improving medication safety by strengthening the systems for reducing medication errors and avoidable medication-related harm in three main areas^​19​:

• High-risk situations (e.g. where the medication being used may be associated with a particularly high risk of harm);
• Polypharmacy, and;
• Transitions of care.

In 2019, the WHO urged countries to prioritise early and sustained action to reduce medication-related harm arising at transitions^​2​. 

In England, as part of the response to the WHO initiative, the secretary of state commissioned research into the prevalence and economic burden of medication errors in the NHS^​20​. This resulted in work being done across England to improve medicines safety, including the nationally commissioned discharge medicines service (DMS). In 2021, a quality improvement guide published by the Royal College of Physicians (endorsed by the RPS) aimed to help organisations improve medication safety when patients leave hospital^​21​. The suggestions from this guide are summarised in Box 1^​21​.

Evidence of interventions to reduce transition of care errors

Several systematic reviews have explored a range of interventions delivered by healthcare professionals, including pharmacy personnel, across the patient pathway both within a hospital setting and post-discharge^​22,23​. These interventions have targeted patient counselling^{​24–27​}, medication reconciliation activities^​25,28​ and specific patient populations^​29​.

However, a 2024 review examining hospital pharmaceutical services at ToC interfaces (such as medication reconciliation, medication analysis and medication management at admission, internal transition and discharge) identified a lack of consistent implementation of such services in high-income countries^​30​. 

The role of community pharmacy

Several studies have explored the positive benefits of community pharmacy teams reviewing patients post discharge from hospitals^{​31–36​}.  One important study, published in 2016, provided evidence to inform the introduction of the DMS within the community pharmacy setting in England^{​37–39​}. This study showed that it is possible to transfer discharge information electronically from secondary care to allow community pharmacy teams to provide a follow-up consultation tailored to the patient’s need and it also indicated that patients may have lower rates of readmission and shorter hospital stays^​37​.  Another paper, which evaluated the discharge medicines review service provided by community pharmacists in Wales, suggested that the scheme was cost saving through reduced emergency attendances, hospital admissions and drug wastage^​40​.

As part of the English DMS, NHS trusts will have considered eligibility criteria (high-risk patients or high-risk medicines) to help identify patients for referral from hospital, reflecting what is known about vulnerable patient groups (e.g. people taking five or more medicines) and specific medicine categories (e.g. anticoagulants, antiepileptics, anti-inflammatories) that may cause harm following transition from secondary to primary care^​38​. The benefits of the DMS for paediatric patients have also been explored^​41​.

Alongside the service delivered by community pharmacy teams, an additional approach to the management of discharge summaries has emerged through the introduction of clinical pharmacists in general practice in England. Therefore, a coordinated approach to the management of discharge summaries by community pharmacy teams and pharmacy teams working in general practice is required to avoid duplication of effort and to ensure joined-up care^​38​. This opportunity for collaboration has been picked up in the primary care patient safety strategy^​42​.

Best practice for pharmacy teams during transitions of care

Secondary care

Various actions by relevant pharmacy teams contribute to safer patient ToC^​43​. In secondary care, medication reconciliation conducted at admission to hospital is the process of compiling a complete and accurate list of a person’s current medicines, comparing this information to the list of medicines prescribed on the drug chart, identifying any discrepancies, resolving them and recording the outcome. This involves various steps and access to different sources of medicines histories^​44​. This information is best gathered within 24 hours of hospital admission. Further considerations are needed during the hospital admission if, for example, patients transition between an intensive care setting to a general ward, especially if different prescribing systems are in operation. Conducting a medication review on the intensive care unit prior to patient transfer and communicating medication changes and plans are particularly important risks that should be addressed^​45​.

Medication reconciliation at discharge involves not just medicines the patient was taking prior to admission, but also the changes made to patients’ treatment plan during their hospital stay.  Changes made to the medicines should be described in the discharge letter and communicated to the patient or carer in a way that they can comprehend the reasoning behind the changes. Such changes might include discontinuing a medicine the patient was taking prior to admission, continuing new medicines commenced during the hospital stay, and restarting a medicine prescribed previously and that was temporarily put on hold during the hospital stay. This communication with the patient may be undertaken, in the main, by pharmacy staff or nurses, with patients receiving patient-friendly ‘medicines list’, as well as a copy of the discharge letter. A checklist for patients has been designed to help make sure they have received the right information^​46​. Referring the patient for the DMS so that their community pharmacy team can help reinforce this communication is an important part of the discharge process.   

Primary care

Following discharge, patients should have a reconciled list of their medicines in their GP record within one week of the GP practice receiving the discharge letter, and before a prescription or new supply of medicines is issued^​12​. Any discrepancies or changes should be carefully reviewed and resolved, and this may require the GP practice pharmacy team to query the information received with the discharging hospital.

In some geographical areas, general practice pharmacy teams may have access to the hospital’s electronic prescribing system and so be able to see the medication journey for their patient. If the discrepancy cannot be resolved in this manner, the query from the practice may be directed to the hospital speciality (e.g. consultant that the patient was admitted under, or to the hospital pharmacy medicines information department).

Community pharmacy teams believe they have a role in patients’ medication management post-discharge, although various barriers have been reported. These include: a lack of information transfer from hospitals; issues with interprofessional communication; time-pressure/workload and staff shortages; patients’ awareness/acceptance of the service; and other patient-related issues, such as a lack of health literacy^​47,48​. As part of the discharge process, the referral of patients for a DMS or a discharge medicines review enables community pharmacy to work effectively with their pharmacy colleagues in general practice to support patients to improve outcomes, prevent harm and reduce readmissions. If new medicines have been commenced in hospital, the community pharmacist may also be able to provide further support via other commissioned services, such as the new medicines service, where this would be clinically appropriate and where the patient meets the eligibility criteria^​39​. 

Conclusion

Recognising the various gaps in the ToC process, pharmacy teams in both primary and secondary care, and in collaboration with other relevant staff, have an important role to play in helping to improve the safety and quality of patient care. In Australia, a stewardship framework approach has been recommended^​49​,  and there may be some aspects of this framework — such as shared decision-making regarding discharge medication planning and medication changes, and multidisciplinary cross-sector case-conferencing for high-risk and complex patients — that could be considered in the UK.