title: Identifying barriers to medication discharge counselling by pharmacists.
abstract: BACKGROUND
  Medication errors may occur more frequently at discharge, making discharge counselling a vital facet of medication reconciliation. Discharge counselling is a recognized patient safety initiative for which pharmacists have appropriate expertise, but data are lacking about the barriers to provision of this service to adult inpatients by pharmacists.
  
  
  OBJECTIVE
  To determine the proportion of eligible patients who received discharge counselling, to quantify perceived barriers preventing pharmacists from performing discharge counselling, and to determine the relative frequency of barriers and associated time expenditures.
  
  
  METHODS
  In this prospective study, 8 pharmacists working in general medicine, medical oncology, or nephrology wards of an acute care hospital completed a survey for each of the first 50 patients eligible for discharge counselling on their respective wards from June 2010 to February 2011. Patients discharged to another facility (rehabilitation, palliative care, or long-term care), those with hospital stay less than 48 h before discharge, and those whose medications were unchanged from hospital admission were ineligible.
  
  
  RESULTS
  Discharge counselling was performed for 116 (29%) of the 403 eligible patients and involved a median preparation time of 25 min and median counselling time of 15 min per patient. At least one documented barrier to discharge counselling existed for 295 (73%) of the patients. Several barriers to discharge counselling occurred significantly more frequently on the general medicine and oncology wards than on the nephrology ward (p < 0.05). The most common barrier was failure to notify the pharmacist about impending patient discharge (130/313 [41%]). Time constraints existed for 130 (32%) of the patients, the most common related to clarification of prescriptions (96 [24%]), creation of a medication list (69 [17%]), and faxing of prescriptions (64 [16%]).
  
  
  CONCLUSIONS
  This study generated objective data about the barriers to and time constraints associated with medication discharge counselling by pharmacists. These findings should raise awareness of the challenges faced by pharmacists in busy hospital positions and may support avenues of change for their hospital discharge counselling programs.
authors: , BSc, BScPhm, ACPR, PharmD, FCSHP, is a Clinician Scientist and is the Pharmacy Lead in Infectious Diseases and Antimicrobial Stewardship, Sunnybrook Health Sciences Centre, Toronto, Ontario.
authors: Sandra A N
authors: SA
authors: Walker
authors: , HBSc, BScPhm, PharmD, was, at the time of this study, a pharmacy student at Sunnybrook Health Sciences Centre, Toronto, Ontario, and is now an Antimicrobial Stewardship Pharmacist (contract position) with the Department of Pharmacy at this institution.
authors: Jennifer K
authors: JK
authors: Lo
authors: , BScPhm, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario.
authors: Sara
authors: S
authors: Compani
authors: , BScPhm, ACPR, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario.
authors: Emily
authors: E
authors: Ko
authors: , HBSc, BScPhm, PharmD, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario.
authors: Minh-Hien
authors: MH
authors: Le
authors: , BScPhm, ACPR, MScPhm, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario.
authors: Romina
authors: R
authors: Marchesano
authors: , BPharm, ACPR, is a Clinical Pharmacist, Sunny-brook Health Sciences Centre, Toronto, Ontario.
authors: Rimona
authors: R
authors: Natanson
authors: , BScPhm, ACPR, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario.
authors: Rahim
authors: R
authors: Pradhan
authors: , BScPhm, ACPR, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario.
authors: Grace
authors: G
authors: Rzyczniak
authors: , BScPhm, ACPR, PharmD, is a Clinical Pharmacist, Sunny-brook Health Sciences Centre, Toronto, Ontario.
authors: Vincent
authors: V
authors: Teo
authors: , BScPhm, ACPR, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario.
authors: Anju
authors: A
authors: Vyas
keywords: barriers to discharge counselling