The Transition of Care Risk: How Pharmacy Software Closes the Safety Gap Between Inpatient and Discharge
The journey from hospital to home, often called “Hospital > Pharmacy > Home” (HPH) Transitions, is a critical point in patient care. While necessary for recovery, this transition is fraught with risks, particularly concerning medication safety. A study on post-hospital discharge in Canadian community pharmacies shed light on the systemic weaknesses and communication breakdowns that put patients at risk and burden community pharmacists.
The Challenge of Discharge
Discharge orders from the hospital can be challenging for patients, their families, and community pharmacists. Community pharmacists are the frontline defense, assessing discharge prescriptions for accuracy, appropriateness, medication education needs, and barriers to access.
However, communication breakdowns and flawed systemic processes are major contributors to risk. When medications are changed in the hospital, patients and pharmacists often lack clear communication from discharge orders, which can lead to avoidable issues such as:
- Delays or omission of therapy
- Unnecessary duplicate healthcare provider work
- Hospital readmissions
These errors are associated with avoidable patient harm and unnecessary pharmacy workload.
Insights from the Study
A study conducted in New Brunswick, Canada, aimed to explore factors increasing the burden on community pharmacies and contributing to patient harm following hospital discharge to home over a 120-day period. The research involved 131 community pharmacies, representing 55% of the pharmacies in the province, utilizing a shared digital incident reporting system.
The results highlighted significant issues:
- Impact of Events: Of the reported events (Medication Safety Events), 55% were “good catches” where the pharmacy prevented harm, but 45% were “incidents” where patient therapy was impacted or led to readmission (harm level of none, mild, or moderate).
- Communication Breakdown: A staggering 55% of reports included unclear guidance on whether to stop, continue, or adjust medications. Furthermore, 41% of patients often lacked understanding of instructions or prescription location.
- Systemic/Process Issues: 66% of issues were traced to hospital discharge prescribing systems. Other issues included:
- Incomplete medication reconciliation (27%)
- Errors in dose, strength, or frequency (30%)
- Missing medications, leading to untreated conditions (23%)
- Workload Impact: 100% of cases involved duplication of work at the community pharmacy level
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The Role of Digital Technology in Safer Transitions
The study’s findings underscore a critical message: while community pharmacists play a key role in preventing harm, systemic communication and process issues continue to create risk during transitions of care.
Importantly, the research — enabled by data collected through the Pharmapod platform — highlights a clear path forward.
1. Linking Sectors Digitally
The study reinforces the need to digitally link hospitals and community pharmacies to increase awareness of medication safety events, improve communication, and enable collaboration directly within shared software systems.
2. Standardized Communication
Findings support the need for standardized, cross-sector communication. A consistent, pharmacist-led discharge summary — supported by digital reporting tools — can ensure that critical medication information follows the patient seamlessly across care settings.
3. System-Wide Learning
The use of a shared incident management system, like Pharmapod, demonstrates how data-driven CQI programs can uncover patterns, share learnings, and drive continuous improvement across the healthcare ecosystem.
Empowering Data-Driven Patient Safety
The New Brunswick study shows how Pharmapod’s digital platform enables evidence-based insights that guide system improvement.
By empowering healthcare teams to report, analyze, and learn from medication safety events, Pharmapod helps turn everyday incidents into actionable data that informs policy, improves collaboration, and ultimately enhances patient safety across transitions of care.
Through digital reporting and shared learning, we move closer to a connected, transparent, and continuously improving healthcare system — one where every transition is safer, and every patient is supported.
