Pharmacist-led Transitions of Care: A Cohort Study on Admission Medication History Factors and Adjustments to the Discharge Medication List.

Patients are at risk of experiencing medication errors during each transition of care (TOC), which can result in adverse drug events and readmissions. Implementing a pharmacist-led TOC service can optimize medication safety and patient outcomes by identifying and correcting medication discrepancies prior to hospital discharge. A pharmacist-led TOC service at a tertiary care center expanded services to review medications at discharge for all enrolled hospitalized patients, but data collection and review had yet to be performed.