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 while admission reviews have reduced risk, discharge remains a weak point: studies show about 40% of patients have medication discrepancies at discharge, about a third of those are clinically significant, and medication problems are implicated in about 20% of readmissions, many of them preventable.

Shane summarized a smaller, four‑hospital study of discharge reviews in which pharmacists evaluated 400 patients. The team found slightly more than one error per patient on average; 41% of patients had errors classified as serious or life‑threatening. Examples she offered included a cancer patient taking aspirin rather than an anticoagulant after a pulmonary embolism, a transplant patient whose dose had been listed at more than twice the actual dose and would have risked toxicity, and a patient prescribed an antiarrhythmic with potential to cause life‑threatening rhythms.

Board members and attendees questioned how hospitals could fund expanded discharge services and whether community pharmacists would be able to follow up. Multiple board members and several public commenters — including hospital pharmacists and representatives of pharmacy organizations — voiced support for expanding the pharmacist review requirement to include discharge for high‑risk patients. Members raised implementation questions such as staffing models (including whether experienced community pharmacists could help as part of hospital teams), the effect of “meds‑to‑beds” programs, and how to reach patients discharged to rehabilitation or long‑term care settings. Presenters and commenters repeatedly said legislation or regulation is often needed to secure funding and staff time in hospitals and to make the practice standard across institutions.

Public commenters — including representatives from the California Pharmacists Association, hospital systems that have implemented discharge pharmacists, and safety organizations — described local successes and urged statewide policy change. Kaiser Permanente, Sutter Health and Cedars‑Sinai representatives described programs using trained pharmacy technicians and pharmacists to obtain histories and perform clinical discharge reviews. Commenters repeatedly said that community pharmacists benefit when inpatient teams correct medication lists before the patient leaves the hospital.

Board members agreed the evidence presented showed a patient‑safety problem and discussed ways the board could help, including possible legislative language or changes to the board’s policies. The board did not adopt binding regulations or a final directive at the meeting; Shane and board members discussed continuing the topic in future meetings and exploring whether the board could provide guidance and support for pilot programs, data collection, and legislation to extend pharmacist responsibilities to discharge medication review for high‑risk patients.

Shane concluded by asking the board to consider extending the existing admission medication‑history law to also require discharge medication accuracy checks for high‑risk patients. Board members thanked her and several said they would offer guidance and may pursue legislative or regulatory options in future rulemaking or committee work.