Case-Based Learning: Resolving Medication-Related Discrepancies During a Pharmacy Care Transition

Abstract

Medication-related discrepancies during care transitions are a prevalent source of preventable harm and adverse drug events in hospitalized patients. Through case-based learning, healthcare professionals, especially pharmacists, can systematically identify, resolve, and prevent such discrepancies. This review synthesizes recent evidence and guideline-based strategies for addressing medication-related discrepancies during transitions of care, emphasizing clinical relevance, mechanisms, and practical implications for interprofessional teams.

Introduction

Transitions of care, such as hospital admission, intra-hospital transfers, and discharge, are high-risk periods for medication errors and discrepancies. These discrepancies defined as unintended differences between prescribed and actual medication regimens may lead to adverse drug events, increased morbidity, prolonged hospitalizations, and readmissions. Case-based learning (CBL) leverages real-world scenarios to bridge knowledge gaps, promote critical thinking, and enhance the systematic approach to medication reconciliation and discrepancy resolution among healthcare providers.

Epidemiology / Disease Burden

Recent studies indicate that medication discrepancies occur in 30–70% of patients during hospital transitions, with clinically significant errors affecting 12–20%. Elderly patients, those with polypharmacy, and individuals with multiple comorbidities are disproportionately affected. The economic burden is substantial, with medication errors contributing to increased healthcare utilization and costs estimated in the billions globally. A 2020 multicenter study in the United States reported that over 50% of hospital readmissions within 30 days were associated with medication-related problems, underscoring the urgency of effective interventions during care transitions.

Pathophysiology

Medication discrepancies arise due to multifactorial issues, including communication failures, incomplete documentation, and system-level inefficiencies. The pathophysiological consequences of such discrepancies may range from subtherapeutic effects to toxicities. Mechanistically, omitted medications can result in disease exacerbations (e.g., heart failure decompensation due to missed diuretics), while duplications or dosing errors may precipitate adverse drug reactions, organ dysfunction, or drug-drug interactions. The dynamic and fragmented nature of care transitions magnifies these risks.

Risk Factors

Several patient, provider, and system-related risk factors contribute to medication discrepancies. Patient-specific factors include advanced age, cognitive impairment, language barriers, and polypharmacy. Provider-related issues encompass lack of medication reconciliation training, time constraints, and incomplete handovers. System-level risks involve fragmented electronic health records, lack of standardized reconciliation processes, and inadequate interprofessional communication. High-risk care settings include emergency departments, intensive care units, and post-acute care transitions.

Clinical Features

Clinically, medication-related discrepancies may manifest as unexplained changes in therapeutic response, new or worsening symptoms, or adverse drug reactions. Common examples include hypertensive crises due to antihypertensive omissions, hypoglycemia from insulin duplications, or bleeding events secondary to inappropriate anticoagulant dosing. Detection often relies on vigilant medication history review, patient or caregiver interviews, and cross-referencing pharmacy records. In some cases, discrepancies remain clinically silent until a sentinel event occurs.

Diagnosis

Accurate identification of medication discrepancies requires a structured medication reconciliation process at every transition point. This involves obtaining a complete and accurate medication history (Best Possible Medication History), comparing the home regimen with current orders, and systematically identifying and resolving intentional and unintentional differences. Advanced tools, such as electronic medication reconciliation platforms and clinical decision support systems, can augment accuracy. Multidisciplinary team involvement including pharmacists, physicians, and nurses is essential.

Treatment & Management

Resolution of medication-related discrepancies necessitates prompt communication and documentation. Evidence-based management includes: 1) immediate correction of errors; 2) patient and caregiver education; 3) updating all medication records; and 4) ensuring clear discharge instructions. Pharmacist-led interventions, such as medication therapy management and post-discharge follow-up, have demonstrated significant reductions in discrepancy-related harm and 30-day readmission rates. Interprofessional case conferences and handoff tools further enhance safety.

Recent Advances / Emerging Therapies

Technological innovations are transforming medication reconciliation. Integration of interoperable electronic health records, automated discrepancy detection algorithms, and telepharmacy services facilitate real-time medication management across care settings. Artificial intelligence (AI) and machine learning models are being developed to predict patients at highest risk for discrepancies and automate alerting systems. Simulation-based CBL modules are increasingly incorporated into pharmacy and medical curricula to build practical skills and reinforce best practices.

Guideline Recommendations

Leading organizations such as the Joint Commission, Institute for Safe Medication Practices, and WHO endorse comprehensive medication reconciliation at every care transition. Key recommendations include: standardized protocols for medication history collection; pharmacist-led reconciliation; patient and caregiver engagement; and documentation of rationale for any medication changes. Ongoing education and competency assessments for all providers involved in transitions of care are strongly advised. Institutions are encouraged to monitor reconciliation outcomes as a quality metric.

Conclusion

Medication-related discrepancies during care transitions remain a preventable cause of patient harm and healthcare inefficiency. Case-based learning provides a pragmatic framework to enhance provider competency, foster interprofessional collaboration, and implement evidence-based reconciliation strategies. Leveraging technology, adhering to guideline recommendations, and prioritizing patient-centered communication are critical for sustainable improvements in medication safety. Ongoing research, education, and system redesign will further reduce the incidence and impact of medication discrepancies in transitional care.