title: Problems with continuity of care identified by community pharmacists post-discharge.
abstract: OBJECTIVE
  Medication discrepancies are common at hospital discharge, and medication reconciliation is widely endorsed as a preventive strategy. However, implementation is difficult for instance due to the unreliability of patients medication histories. In the Netherlands, community pharmacies are well-informed about their patients' pre-admission medication status which enables thorough post-discharge reconciliation. Our aim was to study the frequency and nature of medication discrepancies, missing patient's knowledge and administrative problems at admission to primary care.
  
  
  METHODS
  A cross-sectional study was conducted in pharmacies belonging to the Utrecht Pharmacy Practice network for Education and Research in the Netherlands. Structured checklists were used to evaluate all discharge prescriptions presented by adult patients discharged from the hospital to their own home during the study period. The primary outcome was all possible problems with continuity of care, defined as (i) the number and type of medication discrepancies, (ii) administrative problems and (iii) the necessity for patient education.
  
  
  CONCLUSIONS
  In forty-four pharmacies, checklists were completed for 403 patients. Most discharge prescriptions (92%) led to one or more problems with continuity of care (n = 1154, mean 2·9 ± 2·0), divided into medication discrepancies (31%), administrative problems (34%) and necessity for further education (35%). Medication discrepancies (n = 356) resulted mainly from missing pre-admission medication (n = 106) and dose regimen changes (n = 55) on the discharge prescription. Administrative problems (n = 392) originated mainly from administrative incompleteness (n = 177), for example missing reimbursement authorization forms, or supply issues (n = 150), for example insufficient pharmacy stock. The patients' lack of medication knowledge post-discharge was illustrated by the high need for patient education (n = 406).
  
  
  CONCLUSIONS
  Community pharmacists are still confronted with problems due to inadequate documentation at discharge which can inflict harm to patients if not properly addressed. To reduce these problems, a rigorous implementation of the medication reconciliation process at all transition points, standardized electronic transfer of all medication-related information and interdisciplinary collaboration are crucial.
authors.affiliation: Utrecht University of Applied Sciences, Research Group Process Innovations in Pharmaceutical Care, Utrecht, The Netherlands.|Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.|Zorggroep Almere, Outpatient Pharmacy 'de Brug 24/7', Almere, The Netherlands.
authors.forename: H T
authors.identifier: http://orcid.org/0000-0001-5959-7591
authors.initials: HT
authors.lastname: Ensing
authors.affiliation: Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
authors.forename: E S
authors.initials: ES
authors.lastname: Koster
authors.affiliation: Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
authors.forename: P I
authors.initials: PI
authors.lastname: van Berkel
authors.affiliation: Utrecht University of Applied Sciences, Research Group Process Innovations in Pharmaceutical Care, Utrecht, The Netherlands.
authors.forename: A A
authors.initials: AA
authors.lastname: van Dooren
authors.affiliation: Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
authors.forename: M L
authors.initials: ML
authors.lastname: Bouvy
mesh_terms: D000328:Adult; D000368:Aged; D003157:Community Pharmacy Services; D003266:Continuity of Patient Care; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control; D059065:Medication Reconciliation; D008875:Middle Aged; D010351:Patient Discharge; D010353:Patient Education as Topic; D010595:Pharmacists
keywords: community pharmacy; continuity of care; hospital discharge; medication discrepancies; medication reconciliation; patient counselling; pharmaceutical care; pharmacy practice; safety