Medication Safety After Hospitalization in Patients Prescribed High-Risk Medications

Quick Takes

  • Anticoagulants, diabetes medications, and opioids are three drug classes that should be targeted to prevent adverse drug events.
  • A single home visit by a pharmacist did not impact 45-day medication adverse event rates.
  • Medication adverse events and clinically important medication errors are common following hospital discharge.

Study Questions:

Does a single home visit by a clinical pharmacist shortly after hospital discharge (which includes written educational materials) impact the 45-day incidence rate of adverse drug-related events and clinically important medication errors?


Patients discharged from a 321-bed general medical and surgical hospital and cared for by a multi-specialty physician group practice were eligible. To be included, patients needed to be discharged on at least 1 high-risk medication class (diabetes medication, anticoagulant, or opioid) and met at least 1 of the following criteria:

  • Prescribed at least 2 high-risk medications
  • Have low health literacy level
  • Have low health literacy level
  • Self-report poor medication adherence
  • Have a proxy or caregiver
  • Be discharged on 7 or more medications

Two pharmacists reviewed the medical records of all study subjects and identified all events. Events were adjudicated by 2 other masked physician investigators.


The study was stopped before the planned target enrollment was completed. Of the 361 participants, 100 (27.1%) experienced at least 1 adverse drug event. Overall, there was no difference in unadjusted or adjusted rate ratios of adverse drug events, clinically important medication errors, and the combined adverse drug events and clinically important medication errors, termed adverse drug event incidents.


A single home visit by a pharmacist within 4 days of hospital discharge that included written educational materials, assessment, documentation in the electronic medical record, and communication with providers was no different than mailed educational materials alone in preventing adverse drug-related events and clinically important medication errors.


Published, rigorously designed studies examining pharmacists’ patient interventions are lacking. Therefore, this additional to the literature is welcomed. This single-center clinical trial did not show effectiveness at reducing the 45-day adverse event rate and clinically important medication errors. However, the follow-up period was short, and not every event may have been captured in the medical record. For example, new users of anticoagulants are at particular risk of adverse events over a 6-month period. As mentioned by the authors, their written educational materials provided to the control group were sophisticated and effective. Therefore, medication reconciliation and patients discharge counseling may itself be effective, although not well-studied in rigorously designed trials. Although not stated by the authors, many large health centers at the time were providing pharmacist discharge counseling that included written materials to all patients, particularly those discharged on anticoagulants as required in the Joint Commission National Patient Safety Goals. With the advent of telehealth, future work may be able to reach more patients and permit an evaluation of pharmacy services across a continuum from medication reconciliation performed by hospital pharmacists, telehealth services performed by pharmacists working in “bridge” clinics, and community pharmacists for longer-term care.

Clinical Topics: Anticoagulation Management

Keywords: Drug-Related Side Effects and Adverse Reactions, Medication Errors, Patient Safety, Medication Reconciliation, Patient Discharge, House Calls, Counseling, Pharmacists, Medication Adherence, Telemedicine, Health Literacy, Analgesics, Opioid, Anticoagulants, Insulin

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