Turning risk into opportunity: redesigning medication handover for an ageing population
Kate Gorell

Date and Time

Friday, November 13, 2026, 11:15 AM - 11:30 AM

Theme / Track

Health, medical and integrated care

Presentation Format

Concurrent

Transitions from hospital to residential aged care (RAC) are associated with a high risk of medication discrepancies. Prior research suggests up to 50% of older people encounter at least one medication error due to fragmented and variable information‑sharing during transitions of care. This study compared the accuracy of RAC medication charts before and after implementation of a digitally generated, pharmacist‑reconciled discharge medication package. Methods: A retrospective comparison was undertaken across two acute care of the elderly wards in an Australian metropolitan hospital. A convenience sample of 40 first‑time discharges to RAC were evaluated, comprising 20 pre‑intervention and 20 post‑intervention medication charts. Three clinicians independently screened charts against discharge summaries, with a pharmacist cross‑checking. Errors were categorised as prescription errors or administrative errors. Fisher’s exact tests and Mann–Whitney U tests were used for analysis (α=0.05). Results: Errors were identified in 95% of charts pre‑intervention (131 total errors) compared with 50% of charts post‑intervention (17 total errors), representing a significant reduction in error frequency (p=0.003). Pre‑intervention administrative errors included 14 missing identifiers, two allergy omissions, and three missing medical officer signatures; no administrative errors were identified post‑intervention. Prescription errors decreased from 83 pre‑intervention (67 chart discrepancies and 16 dose errors) to 17 post‑intervention, consisting of 11 medication omissions, five incorrect timing errors, and one dose error. Conclusion: Introducing the digitally generated, pharmacist‑reconciled discharge medication package reduced prescription and administrative errors, highlighting the potential to strengthen medication safety and inform scalable strategies that could enhance discharge processes from hospital to residential care.

Keywords

Implementation, Integrated Care, Medications, Models of Care, Residential

Authors

Ash Smyth, University of Western Australia, Brightwater
Carol Chan, Canberra Health Services
Clare Stephenson, Canberra Health Services, University of Canberra
Chrysta Bridge, Digital Canberra
Kasia Bail, University of Canberra