When a patient is moved from one unit to another, his or her medications should follow.

That's the premise of a pilot Patient-Specific Medication Transfer Program that has helped improve safety, prevent delays in care and reduce wasted medications.

The successful pilot at the Saint Raphael Campus was the result of a WorkSMART idea submitted by an SRC nurse, who recalled a similar program at Saint Raphael's in the past. The previous program and pilot effort were designed to solve a common problem: When patients are transferred to another unit, Pharmacy isn't automatically notified, so partially used, patient-specific medications might not get moved to the new unit. According to regulations, only pharmacists or pharmacy technicians can move medications. The nurse on the new unit frequently calls the Pharmacy to request a new supply of medication and the partially used medication on the former unit is discarded.

"This can result in delays in care while the nurse on the new unit waits for the medication," said Christine Hong, PharmD, associate director of medication safety and pharmacy operations. "It also creates additional work for the nurse and Pharmacy and can lead to higher costs, since these medications, which are customized for each patient, are often expensive."

Hong, who helped create the program previously used at Saint Raphael's, worked with Information Technology Services on the new program. It includes real-time notifications in Epic when patients are transferred to a new unit, so pharmacy technicians can see where and when their patients are moving, along with a list of their medications. Technicians can retrieve transferred patients' partially used medications from Pyxis MedStations on their former unit and put them into Pyxis stations on the new unit. The Epic notification also applies to patients who move to new rooms or beds on their current units, which helps ensure patients receive the correct medications. Patient transfers – within units or to new units – happen an average of two times during an inpatient's stay, Hong said.

With the success of the pilot program, staff with Pharmacy, Nursing, Information Technology Services and other departments are collaborating on a clinical redesign project to expand the program to other areas of Yale New Haven Hospital and, ultimately Yale New Haven Health System.