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Chapter 42. Information Transfer
Harvey J, Murff, M.D.
David W. Bates, M.D., M.Sc.
Harvard Medical School
Patient safety can be compromised by discontinuities in care.
Studies suggest that discontinuity results from poor information
transfer1 and faulty communication,2 which in turn may
cause avoidable adverse events.3
Improving information transfer and communications among
healthcare providers is an important patient safety practice and has been
strongly recommended as a means to improve patient care.1,3-7 This
chapter evaluates safety practices involving improvements of
provider-to-provider information transfer. Practices for evaluation include
transfer of information between inpatient and outpatient pharmacies (Subchapter
42.1), sign-out systems for medical housestaff (Subchapter 42.2), automatically
generated electronic discharge summaries (Subchapter 42.3), and systems to
improve patient notification of abnormal results (Subchapter 42.4).
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Subchapter 42.1. Information Transfer Between Inpatient
and Outpatient Pharmacies
Accurate and timely information transfer between community and
acute care pharmacies is an important safety practice. Patients admitted to the
hospital could benefit from the hospital's pharmacy obtaining better information
concerning their medication allergies as well as prior therapeutic
failures.8 Furthermore, when patients transition from acute care to
outpatient care, changes in medications that occurred during hospitalization may
cause confusion for both patients and providers. In one study surveying patients
one week after hospital discharge, patients' knowledge of their drug indications
were worse for medications introduced during their hospitalization than for
those taken prior to hospitalization (OR 0.69, 95% CI:
Confusion and incomplete information may increase the risk of
under- or overmedication, harmful drug interactions, and other problems.
Existing literature suggests that pharmacist interventions may reduce potential
adverse drug events and have a modest impact on patient morbidity and
mortality.10,11 However, these studies have used independent
reviewers to judge the impact of the intervention and have not specifically
measured adverse drug events or patient outcomes. Clinical pharmacists'
consultations prior to discharge might also improve patient medication
compliance (see Chapter 7).12
Uncontrolled studies report that information-exchange programs
between hospital and community pharmacies are perceived as beneficial and may
have a positive impact on patient outcomes.13 Although not the
primary outcome measured in their small (n=127) observational study, Dvorak et
al did note that using a pharmacy-to-pharmacy referral form was effective in
preventing 2 medication errors. Thus, practices that improve information
transfer between hospital and community pharmacies may improve patient
Of the many potential methods for improving information
transfer between hospitals and outpatient pharmacies, controlled trials have
been reported in the literature for only 2: pharmaceutical care plans
cards14 and patient information facsimiles between
pharmacies.8 Although direct electronic communication of pharmacy
data may be superior to these methods, no controlled studies are currently
available regarding this practice and therefore it is not reviewed within this
In a study by Smith and colleagues, patients received a card
prior to discharge listing their pharmaceutical care plan, which included
medication doses, indications, schedules, side effects, information as to the
importance of drug compliance, and how to obtain medication
refills.14 Patients were instructed to give the card to their
community pharmacist. In another study, the intervention consisted of
pharmacy-to-pharmacy facsimile transmission at the time of admission and
discharge from the hospital.8 In this study, when a patient was
admitted to the hospital their community pharmacy transmitted patient
demographic information, historical information concerning allergies and adverse
drug reactions, current medications, refill history, pharmacist's monitoring
notes, communications with patient and physician, and a detailed medication
history to the admitting hospital. After discharge the hospital pharmacy
transmitted to the community pharmacy a list of any potential medication
problems identified by the hospital pharmacist on admission, the patient's daily
monitoring log, the pharmacist's discharge summary, and a discharge medication
table. The medical records department of the hospital also transmitted the
patient's discharge summary and laboratory test results to the community
Prevalence and Severity of the Target Safety Problem
Medication problems can arise because patients are frequently
discharged from the acute care hospital on medications different from their
ambulatory regimen.15 Elderly patients in particular are at risk
after discharge.16 In one study, hospital providers changed 53% of
the drugs prescribed by the primary care providers.15
The extent to which these medication changes and lack of
communication result in recently discharged patients failing to receive
medications or appropriate monitoring for their drug therapy is unclear. In one
study of elderly patients, 32% of medications prescribed at discharge were not
being taken 2 days after discharge.17 Another study found that 51% of
patients recently discharged from acute care hospitals had deviated from their
prescribed regimen.18 Of those that had deviated from the prescribed
drug regimen, 70% did not understand the medication regimen. In a Scottish
study, recently discharged, elderly patients were issued a 5-day supply of their
medication on discharge and visited in their homes after these 5 days had
elapsed.16 Twenty-seven percent of the patients had not received a
new prescription ordered on discharge. Of the patients with new prescriptions
issued, 19% received inaccurately labeled medications. Medications were
considered mis-labeled when non-specific container labels, such as "take as
directed" replaced the more specific labels given on discharge. Some authors
have suggested that improving communication about medications prior to and just
after hospital discharge might reduce these medication
Poor communication is not the only problem.16
Patient factors influence whether a medication is ultimately picked up and taken
as directed. Deviations from prescribed drug regimens are multifactorial and
improving pharmacy-to-pharmacy communication is only one aspect of the overall
Opportunities for Impact
Data from primary care providers reveal that 96% of the
respondents would like information concerning hospital drug
changes.20 Ninety-four percent of community pharmacists surveyed also
wished to be provided with information concerning hospital drug
changes.20 We were unable to identify data regarding what percentage
of hospital pharmacies routinely transfer information on patients' medication
regimens when they are admitted to and discharged from acute care.
Study Design and Outcomes
Two controlled studies were identified in the literature (Table
42.1.1). Both were randomized trials but neither was blinded. In Smith et al,
patients received a written pharmacy care plan at discharge. Home visits were
made 7 to 10 days later to assess compliance and discrepancies in the medication
that patients were taking versus those ordered at discharge (Level
2).14 In the study by Kuehl et al,8 patients were randomly
assigned to either usual care or to a bi-directional exchange of pharmacy
information by facsimile between the ambulatory pharmacy and the admitting
hospital, upon admission and discharge (Level 1). The outcomes were pharmacist
interventions, such as changing medication doses or making allergy
recommendations (Level 2).8
Evidence for Effectiveness of the Practice
Smith et al's small study (n=53) of a pharmacy care plan card
found that in both groups patients were taking different medications than those
ordered at discharge. The authors found that compliance with post-discharge
medications was significantly better in the group that had received the
information card (p<0.01). Unintentional changes to the medication were found
in 14/28 (50%) of the study patients and 17/25 (68%) of the control patients
during the follow-up visits (Pearson's chi-square p=0.18)
In the study by Kuehl et al, significantly more experimental
group patients than control group patients had at least one in-hospital
pharmacist intervention documented (47% vs. 14%, p<0.001). The mean number of
in-hospital pharmacist interventions per patient was also significantly higher
in the experimental group (1.0 vs. 0.2, p<0.0001). The types of interventions
made by hospital pharmacists included addition of a medication the patient was
taking as an outpatient that was not originally ordered on admission, dosage
changes, and changes related to drug allergy. Interventions by ambulatory care
pharmacists were also more frequent in experimental group patients compared with
control group patients. Community pharmacists who received hospital pharmacy
records performed interventions on one or more patients 42% of the time, while
no interventions were performed in the control group (p=0.001). Specific
community pharmacist interventions included monitoring of therapy (13/57),
taking actions related to drug allergy problems (13/57), requesting
documentation of an indication for a particular medication (9/57), and making a
dosage change (8/57).
Although the data abstractor was blinded with regard to study
group, the nature of the intervention did not permit blinding of participating
pharmacists (i.e., they received faxed information for some patients but not
others). Also, the pharmacists were not explicitly blinded to the study's
objectives. It is unclear how this knowledge might have affected the results. It
could have resulted in more careful scrutiny of any potential drug problem (bias
away from the null) or less scrutiny of these orders (bias towards the null).
Kuehl et al note that although the results suggest discriminatory documentation
did not play a major role, the possibility cannot be ruled out.
Another potential limitation of this study was the completeness
of follow-up. Of the eligible patients from ambulatory care pharmacies, only 50%
returned to their pharmacy during the study period. There were no comparisons
presented between the ambulatory pharmacy visit group and the loss to follow-up
group. This large loss to follow-up could have significantly altered their
Potential for Harm
None of the studies evaluating different hospital-community
pharmacy communication processes detailed any adverse events. However, the
degree of added workload and effects on current workflow must be taken into
Costs and Implementation
The 2 reviewed interventions for improving hospital to
community pharmacy information transfer seemed simple and relatively
inexpensive.8,8,13,14,14 Although no formal cost analysis was
performed, Dvorak et al described their method (use of a pharmacy-to-pharmacy
referral form) as being "labor-intensive." No records were kept of the time
necessary to provide the referrals but the authors estimated the time commitment
per patient to be 30 minutes.13 It is also important to note that
complete information transfers occurred for 75% of the subjects in Kuehl's
study, indicating that there is still room for improving the process. With
improvements in information transfer technology, automated transfer of
information from hospital to community pharmacy could have important patient
safety benefits without excessively increasing providers' workloads.
Providing patients with data forms to convey transfer of
information between hospital and ambulatory pharmacies has potential for
reducing discontinuities resulting from inadequate medication information. Few
studies have evaluated the effect of these interventions on patient outcomes,
although any improvement in the transfer of this information would likely be
well received by ambulatory providers. Future studies are necessary to determine
if and how improved pharmacy-to-pharmacy communications reduce preventable
adverse drug events and improve patient outcomes. Identifying the most effective
and least disruptive forms of inter-pharmacy communication remains an area for
Table 42.1.1. Practices to improve transfer of medication information
||Study Design, Outcomes
||53 patients (>65 yrs old) discharged to home who were likely to
experience difficulties with their medications
||Copies of medication doses, indications, side effects, importance of
compliance and refill information given to patients at
|Patients taking medication not prescribed at discharge: information
card 75%, control 96% (p<0.01) |
||156 patients admitted to small mid-western community
||Pharmacy-to-pharmacy facsimile transmission of medication regimen at
time of admission and discharge from hospital
|Patients with 1 pharmacist interventions in hospital: faxed-summary
47%, control 14% (p<0.001) |
Patients with 1 pharmacist interventions in community: faxed summary
42%, control 0% (p<0.05)
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