Post-discharge medication reviews for patients with heart failure: a pilot study

Pharm World Sci. 2008 Dec;30(6):810-5. doi: 10.1007/s11096-008-9230-7. Epub 2008 Jun 13.


Background: Medication misadventure is greatest at times of change such as the transition from hospital to community. Patients with heart failure are prone to medication misadventure due to polypharmacy, inappropriate medication use and frequent readmissions.

Objective: To identify the barriers encountered when implementing a Liaison Pharmacist facilitated post-discharge medication management service for patients with heart failure.

Method: A Liaison Pharmacist contacted the patient's General Practitioner (GP), sent them a medication discharge summary and organised an appointment for the patient with the GP approximately 2 days post-discharge to make a Home Medicines Review (HMR) referral. The patient's community pharmacist was also contacted, sent a medication discharge summary and requested to engage an accredited pharmacist to undertake the HMR. The Liaison Pharmacist arranged for the HMR report to be sent to the outpatient department clinic to enable assessment of outcomes at the outpatient department follow-up 12 weeks post-discharge.

Main outcome measure: GP HMR referral rates.

Results: 90 patients were offered the service. Fifty-nine patients (66%) agreed to have their GP contacted with 56 GPs agreeing to order a HMR and 41 patients having an HMR post-discharge. Barriers to the implementation of a HMR post-discharge included: patient withdrawal, low GP awareness of the HMR process and conducting the HMR in a timely manner.

Conclusion: This study provides evidence for the feasibility of a post-discharge pharmacy service for patients with heart failure although barriers to implementation have been identified.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Continuity of Patient Care / organization & administration*
  • Drug-Related Side Effects and Adverse Reactions
  • Female
  • Heart Failure / drug therapy*
  • Humans
  • Male
  • Medication Errors / prevention & control
  • Middle Aged
  • Patient Discharge
  • Pharmaceutical Preparations / administration & dosage
  • Pharmacists*
  • Pharmacy Service, Hospital / organization & administration*
  • Physicians, Family
  • Pilot Projects
  • Polypharmacy
  • Professional Role
  • Time Factors


  • Pharmaceutical Preparations