62 Implementation of new discharge process to promote safe transition of care Hamad general hospital

Background Discharging patients from hospital is a critical point of transition of care. Medication errors affect approximately 50% of adult patients discharged, with nearly 20% experiencing adverse drug events post-discharge.¹ Therefore, good discharge medication reconciliation is crucial for safe discharge, reducing hospital readmission, and improving patient outcomes.^{2 3} At Hamad General Hospital (HGH), the discharge pharmacy faces challenges in dispensing medications to complex patients with multiple comorbidities and polypharmacy. Additionally, most discharge prescriptions are written by junior residents thus proper review by clinical pharmacists (CPs) is essential to ensure appropriateness. However, incidents of dispensing medications without CP review have been reported, leading to rework loops, delays in the discharge process, and increased workload for the healthcare team. We aimed to create a lean discharge process and avoid rework loops by standardized process and contribution of clinical pharmacists in refilling at least 20% of discharge orders by November 2022.

Methods A clinical pharmacy-led quality improvement project was undertaken in collaboration with HGH’s discharge pharmacy and nursing leadership. The process involved multiple Plan-Do-Study-Act (PDSA) cycles (figure 1), including identifying causes of medication errors, developing a new discharge process, training CPs to refill orders, and implementing the new process. Additionally, efforts were made to ensure adherence to the new process.

Results By February 2023, Clinical pharmacists covering medical units were trained and actively involved in the new discharge process. They consistently contributed to verifying discharge orders, with a median of 22% which exceeded our target (figure 2).

Conclusion The implementation of the new discharge process has standardized practices, improved communication among the multidisciplinary team, and ensured clinical pharmacist review of discharge orders. By redistributing the pharmacy workload and involving CPs in verifying discharge orders, rework loops were minimized, leading to enhanced patient safety and more efficient discharge procedures.

References

1. Alqenae FA, Steinke D, Keers RN. Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. Drug Safety 2020 Mar 3;43(6):517–37. https://doi.org/10.1007/s40264-020-00918-3 2

2. Pellett C. Discharge planning: best practice in transitions of care. British Journal of Community Nursing 2016 Nov 2;21(11):542–8. https://doi.org/10.12968/bjcn.2016.21.11.542

3. Flatman J. How to improve medication safety at hospital discharge: let’s get practical. Future Healthc J. 2021 Nov 1;8(3):e616–8. https://doi.org/10.7861/fhj.2021-0176

Ethical Approval/IRB Statement The publication of this internal audit and process improvement of the service was approved by the Head of Hamad General Hospital‘s Pharmacy and Nursing Departments.

Disclosures and Acknowledgments The authors would like to thank all clinical pharmacists, discharge pharmacists, and nurses of the medical units who contributed to the success of this project.