Document Type


Publication Date



Purpose: At Stanford Health Care, as part of a hospital-wide initiative to reduce pneumonia readmission rates, an interdisciplinary collaborative effort was created between physicians and transitions of care (ToC) pharmacists to optimize discharge planning and medication management for pneumonia patients. The purpose of this study was to describe the impact of the ToC pharmacist in identifying and reducing medication errors on discharge for pneumonia patients.

Methodology: Retrospective chart review was conducted on patients discharged with a pneumonia diagnosis between December 2015 to Feb 2016. Patients were stratified based on whether they received ToC pharmacist medication review vs. standard of care. Errors were identified by comparing the patient discharge medication list to the physician discharge summary, home, and inpatient medication lists. Errors rates were compared and stratified by error type. Pharmacist interventions were quantified.

Results: Of the 125 patients discharged with pneumonia, 69 patients received ToC pharmacist medication review, while 56 patients received standard of care. In the ToC intervention group, 6 errors were identified for 5 patients, which equates to an error rate of 7.2%. In the standard of care group, 85 medication errors were identified for 36 patients (64.3% error rate). The difference was statistically significant (P < 0.0001) and corresponds to an 88.8% relative decrease. The most common error recorded was incorrect medication/dose/frequency. During this time, the ToC pharmacist had 71 documented interventions.

Conclusions: ToC pharmacist interventions demonstrated a clinically and statistically significant decrease in medication discrepancies, as well as an increased rate of accuracy of the discharge medication list. Continued metrics and interventions are being collected to assess the impact of the ToC pharmacists on patient outcomes. Keywords: Transitions


This article was originally published in California Journal of Health-System Pharmacy, volume 29, issue 6, in 2017.


California Society of Health-System Pharmacists



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.