Choosing Wisely:

Don’t continue medications at transitions of care without a pharmacist or other qualified health care professional performing a comprehensive medication review to verify accurate and complete medication information in concert with current medical problems.

Rationale and Comments: Transitions of care can contribute to serious medication-related problems when transitioning between different care settings. Older adults with complex health care problems appear to be a group particularly at risk for increased adverse events. To mitigate errors in prescribing and transcribing, routine assessments should include a comprehensive medication review, medication reconciliation, and an accurate medication history with the patient and the patient’s advocate. A thorough medication history involves following a systematic process of interviewing the patient, family, or caregiver, and verifying the history with at least one other reliable source of information to determine the complete and correct list of the patient’s actual medication use at the time of the transition. Negative outcomes associated with transitions across health care settings include increased likelihood of polypharmacy when medications are continued that are no longer indicated, therapeutic drug duplication, heightened risk of adverse drug reactions, and poor adherence related to greater complexity of the medication regimen.
Sponsoring Organizations:
  • American Society of Consultant Pharmacists
  • Sources:
  • Systematic reviews
  • Disciplines:
  • Geriatric Medicine
  • References: • Davies EA, O’Mahony MS. Adverse drug reactions in special populations – the elderly. Br J Clin Pharmacol. 2015;80(4):796-807.
    • Weir DL, Lee TC, et al. Both new and chronic potentially inappropriate medications continued at hospital discharge are associated with increased risk of adverse events. J Am Geriatr Soc. 2020;68(6):1184-1192.
    • De Oliveira GS Jr, Castro-Alves LJ, et al. Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials. Journal of Patient Safety. 2017.
    • Kwan JL, Lo L, et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):397-403.
    • Martin P, Tamblyn R, et al. Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomized clinical trial. JAMA. 2018;320(18):1889-1898.
    • Stranges PM, Jackevicius CA, et al. ACCP white paper: role of clinical pharmacists and pharmacy support personnel in transitions of care. J Am Coll Clin Pharm. 2020;3(2):532-545.
    • American Society of Consultant Pharmacists. Pharmacist role in transitions of care. Consult Pharm. 2017;32:645-649.

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