Classification of findings in the home medicine reviews of post-discharge patients at risk of medication misadventure

Abstract

Background: The risk of medication misadventure for patients is greatest during times of change, particularly on discharge from hospital. Patients at high risk of medication misadventure post- discharge should be identified and provided with interventions to ensure the quality use of medicines and positive health outcomes. Home medicines reviews (HMRs) can be used to improve patient health outcomes and reduce the risk of medication misadventure. Aim: To describe the impact of issues raised in post-discharge HMRs, organised via a hospital medication liaison service. Method: HMR reports of participants were evaluated. Issues identified by the accredited pharmacist in each HMR report were classified as either a 'pharmacist intervention' delivered during the HMR or `information given' that was previously unknown to the medical team. A potential clinical impact of these issues was assigned and the overall clinical significance of all the issues identified in each HMR report was ranked. Results: In 21 HMR reports, 98 issues were identified, with the mean per HMR report of 4.7 +/- 2.2. Of the 98 issues, 25 were classified as 'pharmacist intervention' and 73 were classified as 'information given'. On 2 occasions, a potential clinical impact of 4 (potentially life-saving) was allocated to an issue identified in the HMR report. 90% of issues identified in the HMR reports were ranked as clinically significant. Conclusion: This pilot demonstrated that a liaison pharmacist was able to implement a hospital medication liaison model for patients at risk of medication misadventure. Evidence suggests that an HMR conducted post-discharge can identify clinically significant medication-related issues.