Prospective daily review of discharge medications by pharmacists: Effects on measures of safety and efficiency.

PURPOSE: Results of a pilot project to improve the safety and efficiency of the discharge process by adding daily pharmacist review and preparation of discharge medication orders to an existing discharge medication reconciliation workflow are reported.

SUMMARY: Due to patient capacity issues, the pharmacy department of a large tertiary medical center implemented changes to the existing medication discharge workflow. A steering committee was established, with subgroups responsible for workflow development, electronic medical record enhancement, and data collection designated. Patients admitted to 5 hospitalist services, 1 otolaryngology service, and 1 gynecology service were included in pilot testing of a new discharge workflow over a 7-week period. The new workflow included pharmacist daily prospective preparation of discharge medication orders by "pending" (i.e., managing all aspects of) orders for providers to sign. After implementation, a 22% relative reduction ( p = 0.046) in pharmacist-identified medication-related problems was documented. Additionally, the proportion of discharges occurring before noon was increased on all services involved in the pilot project, including a significant increase (from 19% to 23%, p = 0.001) on the hospitalist services. Challenges identified during the pilot project included suboptimal initial provider acceptance and added pharmacist workload. On average, an additional 16.2 minutes of pharmacist time per patient was required for ordering of discharge medications throughout a patient stay.

CONCLUSION: Implementation of a discharge process that incorporated pharmacist pending of discharge medication orders throughout the patient stay improved measures of safety and efficiency of the discharge process.