Board hears call to extend California law so pharmacists review discharge medications for high‑risk patients

The California State Board of Pharmacy on April heard a presentation and widespread public comment calling for the state to require pharmacist review of discharge medication lists for high‑risk patients.

The request, made by Dr. Rita Shane, summarized years of quality‑improvement work and a multicenter study showing that medication‑list errors are common and sometimes life threatening. “I call this the med rec journey,” Dr. Shane said, describing how admission errors can be propagated through a hospital stay and then carried home at discharge. She noted California’s existing law (a pharmacist‑led admission medication‑history requirement enacted as SB 1254) and asked the board and legislators to consider adding a discharge requirement.

Supporters said the change would prevent avoidable harm. The board’s president, Sang Oh, reminded the public: “The board is a consumer protection agency charged with administering and enforcing pharmacy law.” Board members and public commenters from hospitals and pharmacy organizations described frequent discharge problems and endorsed expanding pharmacists’ role at discharge. “When the public doesn’t have systems to ease that transition from discharge to community care settings, we see harm,” Larissa Bethashue of the California Public Health Association told the board.

Dr. Shane reviewed a multicenter quality improvement study conducted at 11 hospitals that analyzed roughly 2,300 medication histories and found errors in 94 percent of med histories and potentially serious or life‑threatening errors in 54 percent of high‑risk patients. In a separate six‑week study of discharge medication reviews across four hospitals, pharmacists identified more than 400 errors (about one error per patient) and classified many as serious or life threatening.

Board members and community pharmacists used the discussion to press on implementation details: how hospitals could prioritize high‑risk patients, how community pharmacists could be looped into the process and how smaller hospitals could staff new duties. “I would love to see work next on that next step, going from a hospital to the community pharmacy,” said board member Nicole Thiebaud, describing barriers community pharmacists face when they try to clarify inpatient orders.

Multiple public commenters — including pharmacy leaders from Sutter Health, Cedars‑Sinai and the California Society of Health‑System Pharmacists — urged legislative action and pointed to readmission and patient‑safety benefits. “We prevent about 61 percent of adverse drug events,” Dr. Shane said of pharmacist discharge review programs, citing published and internal data.

The board did not take regulatory or legislative action at the meeting. Several members encouraged Dr. Shane and other advocates to work with the board’s staff and the legislature during the current sunset and rulemaking processes; board leaders indicated they would accept technical guidance as advocates prepare statutory language and answers for sunset oversight. The conversation concluded with board members offering to continue the discussion at committees and to share input with legislative staff.

The presentation and public comment highlight an ongoing policy choice for California: whether to expand an existing pharmacist requirement tied to admissions to also require discharge medication reconciliation or review for defined high‑risk populations. The board and practitioners signaled agreement on the safety rationale; they left open the practical questions about staffing, funding and the precise statutory language needed to implement a discharge requirement.

Dr. Shane and several hospital and system pharmacists stayed after the meeting to speak further with board members and staff about study data and next steps.