Experts urge board to require pharmacist-led discharge medication reviews after study found frequent, sometimes life‑threatening errors

Doctor Rita Shane, a hospital pharmacist who led multicenter studies of medication‑history errors, told the California State Board of Pharmacy that medication‑list mistakes made on admission tend to propagate through a hospital stay and often reappear at discharge, exposing patients to risk. She described a multicenter quality‑improvement study of 11 hospitals that collected roughly 2,300 pharmacist‑taken medication histories and found that 94% had at least one error and that 54% had an error classified as potentially serious or life‑threatening. Shane said the study captured about 15,850 errors overall and that roughly one‑quarter of those were judged to have potential for serious harm.

Shane said earlier state law, SB 1254, required pharmacy staff to ensure the accuracy of medication profiles for high‑risk patients at hospital admission. The law grew from earlier research showing an average of eight errors per high‑risk admission and, the presenter said, was dedicated to her father after a near‑fatal medication‑history mistake. She told the board that…