Implementation of a pharmacist‑led discharge intervention to improve medication information handover at hospital...

Transitions of care have been identified as high-risk periods for medication-related harm. This feasibility study assessed the reach, adoption, implementation, maintenance and acceptability of a multifaceted intervention designed to improve medicine information handover (patient medicine lists and discharge medicine reconciliation) at hospital discharge in a large public health service in southeast Queensland, Australia.

A non-randomised mixed methods study was conducted, guided by RE-AIM framework. Our primary aim was to determine whether the intervention and study procedures were practical, acceptable, and deliverable in the real-world setting. The population were patients ≥ 65 years of age admitted to hospital for > 24 h on one of three medical wards. The intervention included digital risk stratification, documentation of reasons for medication changes within an electronic medical record, web and paper-based patient information resources, and pharmacist engagement with discharge medications. Quantitative data was used to present recruitment and consent rates, and patient responses to post-discharge survey questions, whilst brief and semi-structured interviews explored clinician participants' perspectives. Inductive content analysis was used on all interview transcripts with deductive mapping to the RE-AIM framework.

Of 36 patients approached, 17 (47%) provided consent and 12 (33%) completed surveys. All invited doctors (n = 20) and pharmacists (n = 3) participated in the intervention. Of the 12 patients surveyed, 11 (92%) felt included in medication-related decisions; nine (75%) followed up with their general practitioner post-discharge, and five (56%) did so within one week. Nine doctors and three pharmacists were interviewed. Clinicians viewed the intervention positively, citing improved workflow, reduced workload and enhanced learning opportunities. Barriers included variable uptake across medical teams, and a need for improved communication and training. Participant feedback suggested the intervention would be sustainable long term once overcoming initial challenges.

The pharmacist-led, multifaceted intervention was feasible and well received by patients, doctors and pharmacists. It improved communication, workflow and shared learning, supporting pharmacist-led medication reconciliation as a scalable model for improving medicine handover. Larger, multi-site evaluations with extended follow-up are warranted to confirm generalisability and effectiveness.

This was a feasibility study that did not meet the definition of a clinical trial under the International Committee of Medical Journal Editors (ICMJE) and was not registered as such.