Background: Pharmacist-led peri-discharge interventions reduce adverse drug events. However, evidence is lacking as to whether there is a business case to fund these non-billable interventions. To test whether such interventions could drive reductions in post-discharge health care utilization to help build a business case, we conducted a pragmatic randomized controlled trial (RCT). Methods: The PHARMacist [...]

Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant [...]

Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant [...]

Background: Adverse drug events (ADEs) result in more than 770,000 injuries and deaths each year and cost up to $5.6 million per hospital, depending on size. The hospital admission is often where the patient is most vulnerable to ADEs. Medication reconciliation on admission is a formal process by which efforts are made to ascertain a [...]

Background: Discharge checklists may reduce medical errors. Traditional paper checklists do not fit into the current workflow in centers that utilize electronic medical records (EMRs). In an era where team-based care is becoming widespread, defining each person’s role in discharge practices is increasingly important.  Methods: Our aim was to develop and implement a standardized discharge [...]

Background: Acutely-ill and multimorbid patients are frequently exposed to unintended medication errors after admission and their impacts on patient safety are profound. Designated ward-pharmacists as team members of our Hospital Medicine Center reconcile medications of hospitalized patients by identifying discrepancies in patients’ current medications and the medication used in acute care in emergency departments or [...]

Background: Growing antimicrobial resistance, C. difficile infection and cost have triggered a greater reliance on antimicrobial stewardship. Most stewardship models rely upon a central team, often led by ID specialists, to oversee prescribing in an institution. However, there are limitations to this paradigm. Purpose: We believe opportunities exist for hospitalists to drive stewardship by integrating [...]

Background: Medication errors during hospital discharge can lead to adverse outcomes, medication-related readmissions, and increased healthcare costs [1,2]. Pharmacist-led medication reconciliation at discharge (PMRD) has emerged as a potential solution to mitigate poor outcomes and optimize medication safety [3-7]. The main objectives of this study were to determine the number of errors identified at discharge [...]

Background: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), affects one to two per one thousand persons annually in the US. Treatment of VTE consists of anticoagulation therapy, and evidence supports treating patients with low-risk VTEs as outpatients.  Novel oral agents such as rivaroxaban, an oral factor Xa inhibitor, require less [...]

Background: Pharmacist-led peri-discharge interventions reduce adverse drug events. However, evidence is lacking as to whether there is a business case to fund these non-billable interventions. To test whether such interventions could drive reductions in post-discharge health care utilization to help build a business case, we conducted a pragmatic randomized controlled trial (RCT). Methods: The PHARMacist [...]