Safe Handover or Lost in Transition?—A Retrospective Evaluation of Pharmacist Referrals to Primary Care Following Hospital Discharge

Q: What does this research mean for the field?

Referral-based communication from clinical pharmacists to general practitioners at hospital discharge yields highly clinically relevant recommendations that are frequently implemented in primary care. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Katarina Wickman; Cecilia Lenander; Gabriella Caleres; Sara Modig

doi:10.3390/pharmacy14050122

August 20, 2026PharmacyOpen Access

Safe Handover or Lost in Transition?—A Retrospective Evaluation of Pharmacist Referrals to Primary Care Following Hospital Discharge

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Why the study?

Inadequate information transfer at hospital discharge poses patient safety risks, and referral-based communication between clinical pharmacists and general practitioners is a novel procedure.

Does referral-based communication between clinical pharmacists and general practitioners at discharge result in the implementation of clinically relevant medication recommendations?

Key Points

To evaluate patient characteristics, the types and clinical relevance of medication-related problems identified by hospital pharmacists, and the subsequent implementation of recommendations by primary care physicians.
Retrospective observational review of pharmacist referrals and electronic medical records between Q4 2021 and Q4 2023 in southern Sweden (N=40 patients with 58 medication-related problems).
Categorized medication-related problems, evaluated recommendation relevance, and measured general practitioner adoption within a 6-month post-discharge follow-up window.
Among included patients (70% female, median age 79.5 years, 75% with extensive polypharmacy), medication adherence issues were the most common problem (22%), and 98% of recommendations were clinically relevant.
General practitioners implemented 77% of assessable recommendations (37/48), with no significant association between clinical relevance and implementation rate (OR 2.27, 95% CI 0.57–9.04, p = 0.247).

Structured PICO

Does referral-based communication between clinical pharmacists and general practitioners at discharge result in the implementation of clinically relevant medication recommendations?

P

Population

40 patients with 58 medication-related problems, median age 79.5 years, 70% women, 75% with extensive polypharmacy, in southern Sweden.

I

Intervention

Referral-based communication between clinical pharmacists and general practitioners (GPs) at hospital discharge.

O

Outcome

Patient population characteristics, medication-related problems, clinical relevance of recommendations, and resulting GP actions (implementation in primary care).

Pharmacist referrals to primary care at hospital discharge provide clinically relevant recommendations that are frequently implemented by GPs, potentially improving medication safety.

Implication

Referral-based pharmacist-GP communication post-discharge may aid medication safety; leaves open effects on outcomes in routine care.

Abstract

The medication-related problems identified by clinical pharmacists during hospitalisation may be better addressed after patient discharge and recovery from acute illness. This approach enables follow-up and may reduce the risks associated with multiple medication changes. However, inadequate information transfer at discharge is a recognised patient safety risk. Referral-based communication between clinical pharmacists and general practitioners (GPs) is a novel procedure in southern Sweden. This retrospective observational study aimed to describe the patient population, medication-related problems, their clinical relevance, and resulting GP actions. Data were collected from pharmacist referrals and electronic medical records between Q4 2021 and Q4 2023. Medication-related problems were categorised, recommendations were assessed for clinical relevance, and follow-up within six months after discharge was analysed to determine whether GPs accepted the recommendations. Forty patients with 58 medication-related problems were included. Women accounted for 70% of the patients, the median age was 79.5 years, and 75% had extensive polypharmacy. Adherence problems were most common (22%). Overall, 98% of the recommendations were considered clinically relevant. Of the 48 assessable recommendations, 77% were implemented in primary care. No statistical association between clinical relevance and implementation was detected (odds ratio 2.27, p = 0.247, CI 0.57–9.04). Pharmacist referrals at discharge may support information transfer and provide clinically relevant recommendations that improve medication safety.