Background: Medication discrepancies are prevalent at various transitions of care including hospital discharge. Medication changes at hospital discharge may be misunderstood by the patient or not conveyed throughout the healthcare system. Most outpatient pharmacy medication records were created for the sole purpose of dispensing prescriptions. Pharmacists have little incentive to remove outdated medications and are rarely instructed to do so by providers. Old prescriptions often remain active until expiring. It is unknown how often medications intended to be stopped by the discharging hospital provider are still active at the pharmacy and/or filled by the patient after discharge.
Methods: A pilot, retrospective observational study that reviewed patient’s discharge records from Mercy Hospital Iowa City and the patient’s outpatient pharmacy in order to quantify how often medications intended to be stopped by the discharging hospital provider are still active at the pharmacy and/or filled by the patient after dischargeInclusion criteria
• The patient had a discontinued medication at discharge with refills remaining at the time of discharge.
• The number of active medications must be more than 4.
• Diagnosis of a terminal condition or hospice enrollment.
• Discharge to a care facility.
• Diagnosis of a psychological or mental disorder that impairs the ability to communicate with the study conductors or requires a representative.
• Under the age of 18
Discharge medication lists were evaluated for discontinuation or substitution of medication therapy. If a patient met criteria and enrolled the patient’s pharmacy was called at 5-10 days and 25-35 days post discharge to determine if prescriptions were active/refilled.
Results: In this study 17/22 (77%) of discontinued medications were still active for sixteen patients at follow up call to the pharmacy 5-10 days after hospital discharge. Some discharge prescriptions included a note to the pharmacist to discontinue prior medications when starting a new prescription; of these, 3/7 (43%) were active at 5-10 days. When compared with those that did not include any instructions 14/15 (93%) were active (p=.001). The relative risk reduction (RRR) for having a discontinued medication with active refills available was 0.54. As of 30 days post-discharge, 4/16 (25%) medications that were discontinued at discharge by the hospital physician had been refilled since discharge.
Conclusions: Discontinued medications are often still active at the outpatient pharmacy (17/22, 77%) after discharge. The prescriber adding a note to the outpatient pharmacist about stopping a medication (a pseudo “prescription to discontinue”) was associated with a lower risk of unintentional prescription persistence. At 30 days after discharge, 4/16 (25%) discontinued medications had been refilled since discharge, representing potential medication errors.