Introduction Transition of care from hospital is a period when the risks of medication errors and adverse events are high, with 50% of adults discharged having at least one medication-related problem. Pharmacist-led medication reviews can reduce medication errors and unplanned readmission when completed promptly postdischarge; however, they are underutilised. A Transition of Care Stewardship pharmacist has been proposed to facilitate and coordinate a patient’s discharge process and facilitate a timely post-discharge medication review. Access to pharmacist medication review in rural and regional areas can be limited. This protocol describes a randomised controlled trial (RCT) to determine whether a virtual Transition of Care Stewardship pharmacist reduces medication-related harm in rural and regional Australia.

Method and analysis Multicentre RCT involving patients at high risk of medication-related harm discharged from regional and rural hospitals to a domiciliary residence. Eligible patients must be aged≥18 years, admitted under a medical specialty, be discharged to a domiciliary setting, have a regular general practitioner (GP) or be willing to visit a GP or an Aboriginal Medical Service after discharge for medical follow-up, have a Medicare card and be at high risk of readmission. High risk of readmission is defined as either a previous admission to the hospital or Emergency Department (ED) presentation in the past 6 months AND≥three regular medications OR on at least ONE high-risk medication. A total of 922 participants will be recruited into the study. Enrolled participants will be randomised to the intervention or control (usual care). The intervention will include a virtual Transition Of Care Stewardship pharmacist to ensure that patients receive discharge medication reconciliation, medication counselling, medication list and communicate directly with primary care providers to facilitate a timely post-discharge medication review. Usual care will include informing the patient’s clinical inpatient treating team that the patient is at high risk of medication misadventure and may benefit from a post-discharge Home Medicines Review (a GPreferred pharmacist medication review funded by the Australian Government).

Data analysis will be performed on a modified intent-totreat basis. The primary outcome assessed is a composite of a first unplanned medication-related hospitalisation or ED presentation within 30 days of hospital discharge. Comparisons between the intervention and usual care groups for the primary outcome will be made using a mixed-effects logistic regression model, adjusting for site-level clustering as a random effect.

Background: Medication-related hospital admissions, including readmissions, are common and often preventable. Identifying these admissions is essential for implementing effective interventions, yet no consensus exists on the most appropriate identification method.

Objective: This systematic review aimed to evaluate the methodologies used to classify medication-related hospital admissions, summarize the tools employed, identify validated tools, and assess their usability in clinical settings.

Methods: A systematic search was conducted in Scopus, PubMed, and Embase following PRISMA guidelines. The review was registered on Open Science Framework (https://doi.org/10.17605/OSF.IO/WEK2D).

Full-text English-language articles published between October 2013 and October 2023 were included if they focused on the development or evaluation of a tool to identify medication-related hospital admissions. Systematic reviews, conference abstracts, editorials, and commentaries were excluded. Studies were screened and selected using Covidence by two authors, with disagreements resolved by a third party. Risk of bias and validity of evidence were assessed using the QUADAS-2 tool and the JBI Critical Appraisal Checklist for Diagnostic Test Accuracy Studies. Data was extracted and evaluated based on usability and if validated, the validation measures.

Results: Twenty-three studies were included which describe three methods for identifying medication-related admissions: trigger tools and indicators (n = 8), questionnaires (n = 4), and author-selected ICD-9 or ICD-10 codes (n = 10). Four studies included validated tools, which were further assessed using QUADAS-2 for risk of bias. The AT-HARM10 tool demonstrated the strongest evidence of validity, with good inter-rater reliability and practical usability (average completion time 5.7 min, useable by pharmacy students). However, most studies showed limitations, including risk of bias, inconsistent definitions, and concentrated in older populations, reducing generalizability. While ICD codes were frequently used, their retrospective design limited their applicability in real-time clinical decisionmaking. These findings highlight the need for standardized, validated tools that are feasible for routine use to improve identification of medication-related admissions and support targeted interventions.

Conclusion: A range of methodologies exists for identifying medication-related hospital admissions, but few are both validated and feasible for clinical use. ATHARM10 was the only tool meeting both criteria, making it the most suitable option for real-time application in clinical settings. These findings underscore the need for standardized, validated tools that are practical for routine use to improve detection and enable targeted interventions. Future research should prioritize validation across diverse populations to improve generalizability and support widespread implementation.

Background: Transition of care from hospital to community is a period that carries significant risk for medication errors, potentially leading to hospital readmission, and causing financial and emotional strain on patients and caregivers. Telehealth technologies offer promising solutions to reduce hospital readmission. Therefore, the goal of this systematic review was to examine the effect of interdisciplinary telehealth post-discharge services that include a medication-focused component on hospital readmissions.

Methods: Following the PRISMA guidelines, a search was conducted in five scientific databases using keywords related to hospital readmission, medication therapy, and telehealth interventions. The review focused on randomised controlled trials published between 2000 and 2023, written in English.

Results: Out of 1,144 papers screened, 23 were included in the review. These studies targeted telehealth service provision to people over 60 years old with chronic illnesses. Various post-discharge telehealth interventions, including medication-focused components, were examined. Most of the interventions were multifaceted, embedded medication-focused interventions with reminders for diet, exercise, symptom check-ups, and education. Among the 23 included papers, 10 studies demonstrated success in reducing readmissions. Seven of these studies targeted patients with heart failure (HF).

Conclusion: Overall, this review highlights the potential of telehealth medicationfocused interventions in reducing hospital readmission rates in patients with HF.

Hospital admission is high risk for medication harm due to transfer errors, delays, and charting mistakes. Up to 70% of admission medication lists contain errors, 59% potentially harmful, highlighting the need for safety strategies. The aim of the study is to systematically review the effectiveness of strategies for medication management at hospital admission. Following PRISMA guideline, three databases were searched for RCTs. Subgroup analyses assessed outcomes including mortality, readmissions/Emergency Department (ED) visits, length of stay (LOS), medication errors, and adverse drug events (ADEs), with meta-analysis where possible. Nineteen RCTs were included. The strategies were classified into five categories: medication reconciliation, supported medication review, collaborative model of medication review, Partnered Pharmacist Medication Charting (PPMC), and real-time health information exchange (HIE) tools. Medication reconciliation alone showed limited effectiveness in reducing medication errors and ADEs while combining with other strategies was more effective in minimizing ADEs. The meta-analysis showed that PPMC can be considered a potential strategy to reduce medication errors and ADEs. Outcomes such as readmission, ED visits, mortality, and LOS were reported as secondary outcomes, and the strategies showed no significant effect in improving them. Overall admission strategies can reduce medication-related outcomes such as medication errors and ADEs; however, stronger evidence is needed to confirm their impact on other outcomes. Future research should focus on integrating Clinical Decision Support (CDS) and stratification tools into electronic medical records to enhance the efficiency of these tools.