Pharmacist’s Role in Transitions of Care

TuTran Nguyen, PharmD

PGY-2 Internal Medicine Pharmacy Resident

IU Health- Methodist Hospital & Butler University

This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.

Medication Discrepancies

Clev Clin J Gen Intern Med. 2010;25(5):441–7.

Question

• What percent of in-patient order errors arise from medication histories?

a. 25%b. 45%c. 65%d. 85%

Impact of Unintentional Discrepancies

Am J Health-Syst Pharm. 2004;61:1689-95. Clev Clin J Gen Intern Med. 2010;25(5):441–7. Am J Health-Syst Pharm. 2009;66:2126-3. Ann Intern Med. 2003;138:161-167.

Question• During which stages have pharmacist’s

intervention(s) resulted in positive impact on patient outcomes?

i. Admissionii. During hospitalization iii. After discharge

a. i & iib. ii & iiic. i & iii d. i, ii, & iii

Pharmacist’s Role

Am J Health-Syst Pharm. 2008;65:857-60. American Journal of Pharmaceutical Education. 2014;78:(2):Article 34:1-5. Arch Intern Med. 2003;163:2014-2018. Am J Health-Syst Pharm. 2009;66:2126-31. Arch Intern Med. 2009;169(21):2003-2010. Arch Intern Med. 2006;166:565-571.

Question

Which of the following characteristic is considered a risk factor for readmission?

a.Greater than 5 medications prior to admission

b.Age >50

c.Greater than 5 comorbid conditions at admission

d.Addition of 1 new medication at discharge

High Risk CharacteristicsCharacteristics

Age >70

Admission in previous months (3-6)

Marital status

>3 Comorbid conditions at baseline

Number of treatment specialists involved in patient’s care

Alcohol/substance abuse

Number of medications at discharge

Medications requiring therapeutic monitoring

Two medication therapies started, changed, or stopped during admission

Documented dementia or confusion at baseline

Documented non-adherence

Dependence on feeding tubes

Presence of pressure sores Arch Intern Med. 2009;169(21):2003-2010. Journal of Hospital Medicine. 2009;4:211–218. Proc (Bayl Univ Med Cent) 2008;21(4):363–372. Q J Med 2011;104:639–651.

JAMA. 2011;306(15):1688-1698. Arch Intern Med. 2012;172(14):1057-1069.

Summary

• The highest potential for medication

errors occur during transitions of care

• Pharmacist interventions decrease

medication errors and improve patient

outcomes

• Closer attention should be paid to high

risk patients

Thank-you!

TuTran Nguyen, PharmD

Email: tnguyen4@iuhealth.org