The risk of adverse drug events

Transcription

1 note Effectiveness of a medication discharge plan for transitions of care from hospital to outpatient settings Lyne Lalonde, Anne-Marie La m p ro n, Marie-Cl au d e Vanier, Pat r i c k Levasseur, Rima Khaddag, and Nesrine Chaar Purpose. The effect of a medication discharge plan (MDP) on the rate of medication discrepancies between hospital and outpatient settings was evaluated. Methods. In a pragmatic, open, randomized, controlled trial, MDPs were completed for all patients before discharge from the hospital. Patients were then assigned to either an MDP group, for whom MDPs were sent to community pharmacies and treating physicians, or a usual care group, for whom an MDP was not sent. Discrepancies between MDPs and community pharmacy dispensing records and medication use reported by patients during a telephone interview were documented. The percentage of patients with discrepancies and the mean percentage of medications with discrepancies were compared between the two groups. The clinical severity of discrepancies was blindly evaluated. Results. A total of 83 patients agreed to participate in the study. The percentage The risk of adverse drug events is high after discharge from an acute care hospital. About 1% of hospitalized patients experience an adverse drug event after discharge, with a half to a third due to human error. 1 It is estimated that 42% of life-threatening and serious adverse events are preventable. 2 The incidence of medication-related hospitalizations varies from 7.5% to 24%, of which 37 72% could be prevented. 3, 4 Discrepancies between discharge medications and those taken at home are frequent. The proportion of patients with at least one discrepancy may be as high as 42 82%. 5-1 In one study, 1% of the discrepancies were considered serious. 9 The rehospitalization rate for elderly patients with identified medication discrepancies (14.3%) has been reported to be significantly higher than for patients without medication discrepancies (6.1%). 11 The medication discharge plan (MDP) has been put forward as a tool for reducing medication discrepancies. An MDP is a complete report of a patient s pharmacotherapy at hospital discharge. It specifies the status of each medication used before hospitalization (i.e., continued with or without changes or discontinued) of patients with at least one discrepancy was high and similar in both groups when MDPs were compared with pharmacy dispensing records and patient self-reports. Comparison of MDPs to pharmacy dispensing records revealed discrepancies for 13 15% of medications; more than a third were clinically significant. Comparison of MDPs to patient self-reports revealed discrepancies for 1 12% of medications; 48% were clinically significant. No significant differences were observed between the two groups. Conclusion. The rate of medication discrepancies was not decreased in patients whose MDP was provided to their community pharmacy and physician at the time of hospital discharge compared with the rate in patients who received usual care. Index terms: Errors, medication; Hospitals; Patient care; Patients; Toxicity Am J Health-Syst Pharm. 28; 65: and new medications added during hospitalization. 12 Many authors have described the use of an MDP 1,13-17 ; however, only one study has evaluated the effect of using an MDP on the rate of medication discrepancies Lyne Lalonde, Ph.D., is Associate Professor; and Marie-Claude Vanier, M.Sc., is Associate Clinical Professor, Faculty of Pharmacy, University of Montreal, Quebec, Canada. Anne-Marie Lampron, M.Sc., is Pharmacist, Centre de Sante et de Services Sociaux du Nord Launaudiere, Centre Hospitalier Regional de Lanaudiere, Quebec. Pat r i c k Levasseur, M.Sc., BCPS, is Pharmacist, Centre de Sante et de Services Sociaux de Laval, Quebec. Rima Khaddag, M.Sc., is Pharmacist, Pharmacie Pierrot Lebrun, Quebec; and Nesrine Chaar, M.Sc., is Pharmacist, Hopital General de Montreal, Quebec. Address correspondence to Dr. Lalonde, Faculty of Pharmacy, University of Montreal, C.P. 6128, Succursale Centreville, Montreal, Quebec H3C 317, Canada (lyne.lalonde@umontreal.ca). Copyright 28, American Society of Health-System Pharmacists, Inc. All rights reserved /8/ $6.. DOI /ajhp7565 Am J Health-Syst Pharm Vol 65 Aug 1,

2 after discharge. 1 The results of that study suggest that an MDP may reduce medication discrepancies between discharge prescription and community pharmacy dispensing records, but it was not a randomized, controlled trial. A pragmatic, open, randomized, controlled trial was conducted to evaluate the effect of an MDP on the rate of medication discrepancies between hospital and outpatient settings as documented by the community pharmacy dispensing records and medication use as reported by patients a few days after hospital discharge. Methods Study design. The trial was conducted at the Cité de la Santé de Laval hospital and in pharmacies in Laval (Quebec, Canada) between October 23 and April 24. The study was approved by an ethics committee, and participants signed an informed consent form. The hospital does not regularly send MDPs to community pharmacists. Patients were recruited before discharge and were randomized into one of two groups: an MDP group, for whom MDPs were sent to the community pharmacies and treating physicians, or a usual care (UC) group, for whom MDPs were not sent. The randomization, blocked in groups of 1, was stratified by medical ward. Group allocation was determined using a computer-generated, random-number table and placed in numbered, sealed envelopes to be opened in strict sequence. Study participants. All pharmacies (n = 66) in the area of Laval received an information letter describing the study. To be eligible, patients had to be at least 18 years old; discharged from a geriatric, family-medicine, or psychiatric ward; discharged with at least two pharmacotherapeutic changes; and have had a medication history taken by a clinical pharmacist during hospitalization. Patients were excluded if they spoke neither French nor English, were transferred to another hospital or rehabilitation center, were unreachable or unavailable for a telephone interview following discharge, had no identified community pharmacy at discharge, had already been recruited into this study during a previous hospitalization, or were unable to provide informed consent. Study groups. MDP group. After discussions with Laval hospital pharmacists, the MDP was adapted from MDPs in current use in other hospitals and at the Cité de la Santé de Laval hospital. The MDP included patient information (name, address, telephone numbers) and contact information (names, telephone numbers) for the hospital physician and pharmacist. It also included the patient s clinical information (weight, height, allergies, intolerances) as well as pharmacotherapy information (drug name, dose, route, frequency, duration) and the pharmacist s recommendations. All medications reported at admission were listed along with their current status at discharge (represcribed without changes, represcribed with changes, discontinued) and new medications added during hospitalization. At the time of hospital admission, ward pharmacists were responsible for documenting medication history. If necessary, the patient s community pharmacy was contacted to complete or confirm the medication history. Medication changes during hospitalization were documented from the hospital pharmacy medication administration records, physicians prescriptions, and pharmacists notes. All patients received the comprehensive pharmaceutical care routinely provided by hospital pharmacists during their hospital stay and at discharge. This includes obtaining medication history, chart documentation, case discussion with physicians, and patient counseling at discharge. An MDP was completed for each patient in the MDP group. If discrepancies were observed between the MDP and the discharge prescription, pharmacists were responsible for reconciling the information. However, on rare occasions, MDPs were completed before the discharge prescriptions were finalized. MDP patients received a copy of the MDP, and a copy was faxed to their treating physician and pharmacy or long-term care pharmacist. UC group. All patients assigned to the UC group received similar pharmaceutical care during their hospital stay and at discharge. An MDP was completed for each UC patient; however, a copy of the MDP was not given to patients and was not sent to their treating physician and community pharmacy. Patients received a conventional hospital discharge prescription and, if relevant, a medication administration schedule with or without medication information leaflets. For all MDP and UC patients, the MDP was completed before randomization. Data collection. A pharmacist systematically interviewed patients by telephone approximately one week after discharge. Patients were asked when and where they had their discharge prescription filled and the name and dosage taken of each of their medications (medication, dosage, route of administration, duration of use). The patient s community pharmacy was then contacted to obtain a listing of the patient s active medications available from the dispensing records. A medication was considered active if it was either dispensed within the past 3 days or renewed in the past 12 months and not specifically discontinued by the community pharmacist. Evaluation of discrepancies. Medication discrepancies were evaluated between the MDP, considered as the standard for purposes of the study, and three other sources of information: the discharge prescription, the patient s community pharmacy dispensing records, and the patient s 1452 Am J Health-Syst Pharm Vol 65 Aug 1, 28

3 medication self-report. Using MDP information, the status of each medication at discharge was classified into one of five categories: represcribed without changes, represcribed with changes, added during hospitalization, discontinued during hospitalization, and not reported in the MDP. In addition, for medications in the first three categories, the discrepancy was further defined as a medication reported in the MDP only or a different medication dosage reported (including discrepancies regarding the dosage, route of administration, frequency of use, and duration of use). A clinical pharmacist and a familymedicine physician individually and blindly assessed the potential clinical effect of each discrepancy. Severity was assessed as not clinically significant, clinically significant but not life threatening, serious (i.e., life threatening or may cause major clinical problem or hospitalization), not enough information to judge, or not applicable (discrepancy judged to be due to an MDP error). 18 Statistical analyses. All analyses were made on the basis of an intentto-treat approach. The patient was used as the unit of analysis. This is essential to ensure that all observations are independent from each other. For each study group, the proportion of patients with at least one discrepancy was computed. For each patient and each source of information, the percentage of discordant medications was computed. For each study group, the mean percentage of discordant medications per patient and standard deviation, also expressed as a percentage, were then computed. The statistical significance of the differences was assessed with a Student t test. This analysis was made to compare overall discordance, discordance by medication status, and discordance by clinical severity level. Based on the results of the study conducted by Paquette-Lamontagne et al., 1 where the proportion of patients with medication discrepancies was reduced from 6% to 2% with the MDP, it was estimated that 34 patients per group would be required to detect a 4% difference between the proportion of patients with at least one discordance between the MDP and the community pharmacy dispensing records, assuming a Type I error of 5% and a power of 9%. Results During the study, 385 patients were discharged from the geriatric (n = 151), psychiatric (n = 59), and family-medicine (n = 175) wards. The majority were ineligible to participate because they were transferred to a rehabilitation center, did not have at least two changes in drug therapy, were unable to provide informed consent due to dementia, or left the hospital too soon to be asked. In all, 95 patients (25%) were approached and 83 (87%) agreed to participate (MDP group: 42; UC group: 41). Copies of the discharge prescriptions were obtained for 65 patients and copies of the community pharmacy dispensing records were obtained for all patients but 1. Six patients could not be contacted for the telephone interview. Patient characteristics were similar in the two groups (Table 1). The majority were elderly women living in a private home and discharged from the geriatric or family-medicine ward. At discharge, 79% of MDP patients and 66% of UC patients received counseling by a pharmacist. Over 95% of discharge prescriptions were verified by a pharmacist. Patients left the hospital with a mean of 1 prescribed medications. During hospitalization, MDP and UC patients had a mean of 8.7 and 7.7 drug therapy changes, respectively. Medication discrepancies. When MDPs were compared with discharge prescriptions, 452 medications were documented for MDP patients and 368 for UC patients. The mean ± S.D. percentage of discrepancies per patient was 19.1% ± 17.7% (Table 2). The main source of discrepancies was missing information on discharge prescriptions about medications represcribed without changes (6.6%) or discontinued during hospitalization (1.1%). Other types of discrepancies emerged less frequently and involved medications represcribed with changes (.2%), medications added during hospitalization (1.7%), and medications reported in the discharge prescription but not in the MDP (.5%). These discordances may be attributed to errors in either the discharge prescription or the MDP. Comparative results for medication discrepancies per patient between the MDP and the community pharmacy dispensing records and patient self-reports are provided in Table 3. When MDPs were compared with community pharmacy dispensing records, 537 medications were documented for MDP patients and 499 for UC patients. A total of 66% of MDP patients and 68% of UC patients had at least one discrepancy (p =.8). The mean percentage of medications with discrepancies was similar in the two study groups (MDP: 13.2%; UC: 15.3%; p =.6) (Table 3). The most common discrepancies involved medications not reported in the MDP but documented in the community pharmacy dispensing records (MDP: 5.%; UC: 5.7%; p =.7). Comparison of MDPs and patients medication self-reports revealed that 62% of MDP patients and 58% of UC patients had at least one medication discrepancy (p =.7). The mean percentage of medications with discrepancies was also similar in both groups (MDP: 1.3%; UC: 12.1%; p =.6) (Table 3). Clinical severity of discrepancies. The comparative results of severity assigned for discrepancies between the MDP and community pharmacy dispensing records and patient selfreports for both groups are provided in Table 4. In all, 68 discordances between MDPs and pharmacy records were observed in the MDP group and Am J Health-Syst Pharm Vol 65 Aug 1,

4 Table 1. Patient Demographics and Characteristics Characteristic Mean ± S.D. age, yr Female, no. (%) Place of residence, no. (%) Private home Residence for elderly people Long-term-care facility Living with someone else, no. (%) No Yes Highest level of education completed, no. (%) None Primary school High school College or vocational school University Hospital ward, no. (%) Geriatric Family medicine Psychiatric Other Patient counseling by hospital pharmacist at discharge, no. (%) On all medication On some of medications None Discharge prescription verified by hospital pharmacist, no. (%) Mean ± S.D. no. medications on discharge prescription Mean ± S.D. no. pharmacotherapeutic changes during hospitalization Mean ± S.D. no. medication daily intakes on discharge prescription Use of a pill organizer, no. (%) Home-care services, no. (%) 77 in the UC group. On average, over a third of the discrepancies (MDP: 34.3%; UC: 37.4%; p =.8) were clinically significant but not life threatening. Serious discrepancies were observed less frequently than other types of discrepancies in both groups (MDP: 3%; UC: 5.9%; p =.5). There were 51 discrepancies between MDPs and patient self-reports observed in the MDP group and 58 in the UC group. The mean percentage Medication Discharge Plan Group (n = 42) 69.8 ± (73.8) 29 (69.) 11 (26.2) 2 (4.8) 17 (4.5) 25 (59.5) 24 (57.1) 9 (21.4) 4 (9.5) 4 (9.5) 2 (47.6) 16 (38.1) 4 (9.5) 2 (4.8) 33 (78.6) 9 (21.4) 4 (95.2) 1.4 ± ± ± (38.1) 25 (59.5) Usual Care Group (n = 41) 72.8 ± (73.2) 32 (78.) 8 (19.5) 21 (51.2) 2 (48.8) 28 (68.3) 6 (14.6) 3 (7.3) 3 (7.3) 21 (51.2) 16 (39.) 3 (7.3) 27 (65.9) 8 (19.5) 6 (14.6) 4 (97.6) 9.6 ± ± ± (34.1) 16 (39.) of discrepancies that were considered to be clinically significant but not life threatening in both groups was approximately 48%, and no significant difference was observed between the groups (p =.6). However, the rate of serious discrepancies was significantly higher in the MDP group (MDP: 13.5%; UC:.7%; p =.2). Discussion In this study, an MDP was completed for each patient before hospital discharge. For patients in the MDP group, a copy of the MDP was given to patients and sent by fax to their treating physician and community pharmacy. For patients in the UC group, the MDP was not given to patients and not sent to their treating health professionals but it was used for comparison purpose. The results indicate that, after hospital discharge, overall about two thirds of patients had at least one medication discrepancy between the MDP and the community pharmacy dispensing records and more than half reported taking their medications differently than documented in the MDP. The mean proportion of medication discrepancies per patient varied from 13% to 15% based on the community pharmacy dispensing records, and more than a third of them were clinically significant. Fewer discrepancies were observed between the MDP and the medication use as reported by patients (1 12%), but nearly 5% of them were considered clinically significant. No differences were observed between the study groups, suggesting that sending an MDP did not reduce the rate of medication discrepancies between hospital and outpatient settings. A few studies suggested that medication discrepancies after hospital discharge may be reduced by providing the services of seamless care pharmacists 6,17,19 or implementing a multidisciplinary approach to optimize medication reconciliation. 2 To our knowledge, only the Paquette- Lamontagne et al. 1 study specifically evaluated the effect of an MDP. In that study, the MDP was integrated into the discharge prescription and was therefore considered as a legal document. Compared to the usual care, this approach significantly reduced medication discrepancies with pharmacy records from 6% to 18%. In the context of hospital discharge, an MDP s ability to re Am J Health-Syst Pharm Vol 65 Aug 1, 28

5 Table 2. Comparison of Medication Discrepancies Between the Medication Discharge Plan (MDP) and the Discharge Prescription a Variable Overall discordance Discrepancy in medication status as defined in discharge plan Medication represcribed at discharge without changes Medication represcribed at discharge with changes Medication added during hospitalization Medication discontinued during hospitalization Medication not reported in MDP Mean ± S.D. Discrepancies Per Patient (%) 19.1 ± ± ± ± ± 1..1 ±.7.1 ± ± ± ± ± 2.6 a n = 65. Data were missing for 18 patients because they left the hospital with their discharge prescription before the researchers could record it. duce medication discrepancies rests mainly on two factors: accuracy of the MDP and efficient transfer of information. In real-life conditions, providing accurate MDPs may prove challenging since it is influenced by the quality of medication reconciliation between the outpatient and the hospital settings and within the hospital itself. Our data suggest that, even in the MDP group, medication reconciliation between the hospital and outpatient settings was incomplete. We found that 38% of discrepancies between MDPs and community pharmacy dispensing records were due to medications documented in the pharmacy records but not in the MDPs. The reason may be incomplete medication histories taken at hospital admission or the failure of community pharmacists to inactivate unused or discontinued medications in their records. When comparing the MDP and patient self-report, this type of discrepancy accounted for 17% of all discrepancies, again suggesting that this type of discrepancy may partly be attributable to incomplete medication histories at admission. Medication reconciliation was also not optimal in the hospital setting. When MDPs were compared with discharge prescriptions, there were discrepancies for 19% of medications. In two studies, the proportion of unexplained discrepancies between preadmission medication regimens and discharge medication prescriptions reported was 49% 6 and 41%, 21 respectively. Varkey et al. 2 reported that a systematic, multidisciplinary reconciliation process resulted in a lower discrepancy rate of 19.5% between discharge prescription medications and medication information as documented from the hospital medical file. Notably, 78% of these discrepancies were considered minor and the majority were accounted for by failure to reconcile home asneeded and nonprescription medications. Nickerson et al. 8 reported that discrepancies at discharge were reduced to 9% through rigorous medication reconciliation by a clinical pharmacist. Use of an electronic medication-information transfer tool interfaced with a hospital patient-information system could improve MDP quality; such a tool has been studied and was well received by pharmacists and patients. 22 A reconciliation process alone may not be sufficient to optimally reduce discrepancies. Schnipper et al. 6 showed that despite a complete medicationreconciliation process in conjunction with patient counseling at discharge, a high proportion of patients still presented medication discrepancies (71%) at telephone follow-up by a pharmacist three to five days after discharge. However, unexplained discrepancies were found for only 29% of patients, and the rate of preventable adverse effects was reduced from 11% to 1% in the intervention group. No MDP was sent to a community pharmacist in that study. To be effective, a MDP must be received in a timely fashion. In our study, the MDP was faxed to the community pharmacy and treating physician at the time of patient discharge and was probably received before the patient s first visit to the pharmacy after discharge. A copy was also given to patients with their prescriptions; however, unreliable delivery of MDPs to community pharmacists by patients has been previously reported. 23,24 Using an MDP with the medication discharge prescription ensures that the information gets to the community pharmacist at the time of dispensing. 1,14 Still, community pharmacists who are unfamiliar with MDPs may not easily incorporate the information into their patient s records. Dvorak et al. 24 observed that, although community pharmacists consider MDPs a useful tool, they manage to incorporate only 62% of the information into their patient file. There were limitations to our study. The pragmatic approach selected to conduct this randomized, controlled trial was essential to measure the real-life efficacy of an MDP. Current ward clinical pharmacists Am J Health-Syst Pharm Vol 65 Aug 1,

6 Table 3. Comparisons of Medication Discrepancies in Community Pharmacy Dispensing Records and Patient Self-Report a Mean ± S.D. No. Discrepancies a MDP vs. Patient Self-Report MDP vs. Community Pharmacy Records Usual Care Group (n = 38) (n = 39) Usual Care Group (n = 41) (n = 41) Variable 12.1 ± ± ± ± ± ± ± ± 2.8 b 1. ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 8.7 Overall discordance Discrepancy in medication status as defined in discharge plan Medication represcribed at discharge without changes Medication represcribed at discharge with changes Medication added during hospitalization Medication stopped during hospitalization Medication not reported in MDP a Unless otherwise stated, p was not significant for any comparisons. MDP = medication discharge plan. b p =.3. without any specific training completed the MDP at discharge, and 52 pharmacies participated in the study. The participation rate among eligible patients was high (87%), and data collection was completed for almost all patients. However, generalization was limited by the fact that the MDP was evaluated among a small number of patients in only one large community hospital. Furthermore, the MDP was implemented and evaluated simultaneously, and there was no opportunity to improve the process over time. Consequently, its use might not have been optimal. Under real-life conditions, the rate of medication discrepancies after hospital discharge is high and clinically significant. Sending an MDP to a community pharmacy and the treating physician at hospital discharge did not reduce medication discrepancies in our study. Our suggestions for improving the effectiveness of MDPs include the provision of current patients medication lists by community pharmacies, appropriate training of hospital and community pharmacists, implementing rigorous medication reconciliation throughout hospitalization, an integrated MDP with medication discharge prescription to ensure availability of information at the time of dispensing, using an electronic medication-information transfer tool interfaced with a hospital patient-information system, and providing seamless-care pharmacists to help resolve medication discrepancies after discharge. Conclusion The rate of medication discrepancies was not decreased in patients whose MDP was provided to their community pharmacy and physician at the time of hospital discharge compared with the rate in patients who received usual care. References 1. Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 26; 174: Am J Health-Syst Pharm Vol 65 Aug 1, 28

7 Table 4. Severity of Individual Medication Discrepancies Severity of Discrepancy Not clinically significant Clinically significant but not life threatening Serious Not enough information Not applicable MDP vs. Community Pharmacy Dispensing Records (n = 41) 53.8 ± ± ± ± 32.8 Mean ± S.D. Discrepancies Per Patient a (%) Usual Care Group (n = 41) 5.8 ± ± ± ± 22.3 a Unless otherwise stated, p was not significant for any comparisons. MDP = medication discharge plan. b p =.2. (n = 39) 33.7 ± ± ± ± 21.6 MDP vs. Patient Self-Report Usual Care Group (n = 38) 4.4 ± ± ± 3. b 4.6 ± ± Bates DW, Cullen DJ, Laird N et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. JAMA. 1995; 274: Baker GR, Norton PG, Flintoft V et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 24; 17: Samoy LJ, Zed PJ, Wilbur K et al. Drugrelated hospitalizations in a tertiary care internal medicine service of a Canadian hospital: a prospective study. Pharmacotherapy. 26; 26: Moore C, Wisnivesky J, Williams S et al. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 23; 18: Schnipper JL, Kirwin JL, Cotugno MC et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 26; 166: Duggan C, Feldman R, Hough J et al. Reducing adverse prescribing discrepancies following hospital discharge. Int J Pharm Pract. 1998; 6: Nickerson A, MacKinnon NJ, Roberts N et al. Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthc Q. 25; 8 (Spec No): Foss S, Schmidt JR, Andersen T et al. Congruence on medication between patients and physicians involved in patient course. Eur J Clin Pharmacol. 24; 59: Paquette-Lamontagne N, McLean WM, Besse L et al. Evaluation of a new integrated discharge prescription form. Ann Pharmacother. 21; 35: Coleman EA, Smith JD, Raha D et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 25; 165: Institute for Healthcare Improvement. Getting started kit: prevent adverse drug events. (accessed 27 Aug 13). 13. Bergeron J, Laprise R, Mallet L. Pharmacy discharge plan for continuity in patient care. Can Pharm J. 1998; 131: Rogers K, Tierney M, Singh A et al. Assessment of a seamless care prescription / discharge notes form. Can J Hosp Pharm. 23; 56: Cameron B. The impact of pharmacy discharge planning on continuity of care. Can J Hosp Pharm. 1994; 47: Cole DL, Slayter KL. Evaluation by patients and pharmacists of a summary form for seamless pharmaceutical care. Can J Hosp Pharm. 1999; 52: Pickrell L, Duggan C, Dhillon S. From hospital admission to discharge: an exploratory study to evaluate seamless care. Pharm J. 21; 267: Lipton HL, Bero LA, Bird JA et al. The impact of clinical pharmacists consultation on physicians geriatric drug prescribing. A randomized controlled trial. Med Care. 1992; 3: Bolas H, Brookes K, Scott M et al. Evaluation of a hospital-based community liaison pharmacy service in Northern Ireland. Pharm World Sci. 24; 26: Varkey P, Cunningham J, O Meara J et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health-Syst Pharm. 27; 64: Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 26; 15: Cesta A, Bajcar JM, Ong SW et al. The EMITT study: development and evaluation of a medication information transfer tool. Ann Pharmacother. 26; 4: Smith L, McGowan L, Moss-Barclay C et al. An investigation of hospital generated pharmaceutical care when patients are discharged home from hospital. Br J Clin Pharmacol. 1997; 44: Dvorak SR, McCoy RA, Voss GD. Continuity of care from acute to ambulatory care setting. Am J Health-Syst Pharm. 1998; 55:25-4. Am J Health-Syst Pharm Vol 65 Aug 1,