Transition between hospital and ambulatory care is a delicate step, which involves several healthcare professionals and presents a considerable risk of drug related problems. The community pharmacist plays an active role in preventing and solving medication errors and can increase patient safety.

A study was conducted in 14 community pharmacies surrounding a Swiss hospital. Patients discharged from the internal medicine ward of the hospital, taking more than four drugs chronically and capable of discernment were included in the study upon their approval. For each hospital discharge prescription, community pharmacists collected data about all the interventions performed and time needed for prescription validation. Analyses of the number and type of pharmaceutical interventions and propositions, time spent on discharge prescriptions and number of medication changes during transition of care were performed.

Sixty-four patients were included in the study. The total number of interventions done by community pharmacists on the 64 discharge prescriptions was 439, representing a mean of 6.9±3.5 (range: 1–16) interventions per patient. No hospital discharge prescription required zero interventions and 61 prescriptions (95%) needed a phone call to the patients’ hospital physician. Most frequent pharmaceutical interventions were: confirming voluntary omission of a drug taken before hospitalisation (31.7%), treatment substitution (20.5%), different dosage compared to history (16.9%), reimbursement issues (8.8%), optimization of galenic formulation (6.6%) and confirming drug omission (6.3%). Roughly half (52%) of hospital discharge prescriptions required between 10 and 20minutes for pharmaceutical validation, whereas 14% required less than 10minutes and 6% more than 40minutes. The most frequent pharmaceutical proposition was the use of a pillbox. In average, there were 17 medication changes per patient at different steps of the transition of care: 10 changes between hospital admission and discharge, 3 changes between hospital discharge and community pharmacy, and 4 changes between community pharmacy and general practitioner appointment.

Hospital discharge prescriptions are often complex and present a risk of medication errors. The community pharmacist plays a key role in preventing and identifying drug related problems, but time required for pharmaceutical validation might be a constraint. Medication reconciliation at hospital admission and a better communication of medication changes at discharge may facilitate community pharmacists’ work, ensure continuity of care and thus increase patient safety.