American Society of Health-System Pharmacists

View all recommendations from this society

June 1, 2017; updated July 28, 2021

Do not prescribe patients medications during care transitions (i.e. hospital discharge, long term care facility, between different healthcare professionals, etc.) without verifying that these all medications have an indication and are still needed, and that discharge any new medications will not result in duplication, drug interactions, or adverse events.

Treatments and procedures during a hospitalization or other institutionalized stay may impact a patient’s ongoing need for a medication they were receiving prior to admission. Care should be taken at discharge to consider each medication taken prior to admission in light of the patient’s current state. Transitions of care in non-institutional settings, such as patient transitioning among multiple healthcare professional visits should also be considered a transition of care risk. Unnecessary medications should be discontinued, duplicate or overlapping therapies should be changed, and the specific changes should be clearly communicated to the patient/caregiver and the patient’s healthcare team (i.e. primary care clinician, specialists, the patient’s pharmacy). The Joint Commission recommends a thorough medication review at admission and discharge to prevent any unnecessary medications being continued. Medication-use experts should partner with patients and the inter-professional care team to identify, assess, and resolve barriers to medication access, adherence, and health literacy to establish consistent and sustainable models for seamless transitions of care.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

A task force made up of pharmacists from all practice settings was formed. The task force was oriented to the criteria used to establish Choosing Wisely lists and already established recommendations. Based on this information and on their knowledge of how medications are prescribed, dispensed, and administered, the task force developed an initial list of recommendations. Over time this list was vetted, evaluated, researched, and referenced. Through a consensus process over time the list was prioritized down to a total of five recommendations. This list was approved by the ASHP Board of Directors.

Sources

Varkey, P, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health-Syst Pharm. 2007; 64:850-5.

Najafzadeh M, et al. Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge. Am J Manag Care 2016; 22:654-61.

Lehnbom, EC, et al. Impact of medication reconciliation and review on clinical outcomes. Ann Pharmacother. 2014; 48:1298-1312.

The Joint Commission. 2017 National Patient Safety Goals. www.jointcommission.org/standards_information/npsgs.aspx (accessed 2017 Jan 21).

ASHP Practice Advancement Initiative 2030: New recommendations for advancing pharmacy practice in health systems. Am J Health-Sys Pharm. 2020; 77:113-122.