Innovation update: Transforming LTC transitions

New CFP-funded research provides important new insights into medication incidents and near-misses when patients transition to long-term care homes—and the indispensable role of pharmacists in preventing harmful adverse events.

The findings illuminate a largely unseen aspect of pharmacist practice: identifying, investigating, and resolving medication discrepancies before they result in adverse outcomes. They also demonstrate the value of systematically capturing and learning from near-misses and intercepted errors, events that rarely receive the same attention as incidents that ultimately reach patients.

Funding for the project was made possible through a donation to the Canadian Foundation for Pharmacy’s Innovation Fund from the Coalition of Pharmacists Caring for Aging Canadians prior to its dissolution in 2024.

The study, led by Ghafari, is a collaborative effort with her team and pharmacists participating in medication reconciliation and incident review activities. Angela Ho conducted the detailed review and analysis of medication incidents that informed the study’s findings. The incidents occurred between July and December 2025.

Residents in the analysis were medically complex, with an average age of 79.4 years, 13.1 comorbidities and 15.5 active medications. Forty-one of the 50 incidents involved residents arriving from hospital settings, “highlighting the importance of medication reconciliation and accurate information transfer during hospital to long-term care transitions,” says Ghafari. Omitted medications (32%) and medications inappropriately resumed (26%) were the most common incident types, while one in five cases involved high-alert medications such as opioids.

Beyond the findings, the project has designed an electronic documentation framework to standardize the capture of medication incidents and near-misses during transitions of care. The framework is intended to strengthen reporting consistency and data quality and to create a foundation for future research and quality improvement.

CFP spoke to Ghafari about the importance of these findings, and future objectives.

Why did you feel it was important to do this research?

Throughout my career, I have seen that transitions of care are often where the healthcare system is most vulnerable to medication errors. Information must be transferred across numerous providers and organizations.

What motivated this work was seeing the same types of medication discrepancies and near-misses recur. Pharmacists were identifying and correcting these issues every day, but very little of that learning was being systematically captured. Not every organization or care setting has a dedicated medication reconciliation program like ours to review a patient’s medications at the point of transition. I felt we had an opportunity, and arguably a responsibility, to move beyond simply preventing individual incidents to understanding the broader patterns behind them. By identifying common contributing factors, we can help strengthen the systems intended to protect residents during transitions.

I was also motivated by a desire to showcase the tremendous impact pharmacists have on patient safety. Much of this work occurs behind the scenes and successful interventions often go unnoticed because the adverse event never happens. Ultimately, I hope this project not only improves medication safety but also highlights the importance of pharmacist-led medication reconciliation and supports ongoing investment in this highly specialized area of pharmacy practice.

What is your immediate objective for knowledge translation?

Our immediate focus is translating these findings into meaningful system-level improvement. One important opportunity is to create feedback loops with referring care settings. Many of the medication incidents and near-misses during transitions into long-term care originate earlier in the care journey, in parts of the healthcare system that are outside our sector’s direct accountability.

Creating that feedback loop gives referring organizations an opportunity to understand recurring risks, strengthen their own processes, and help prevent similar incidents in future transitions. In this way, the learning from medication reconciliation can support improvement not only within long-term care, but across the broader healthcare system.

Tell us more about the electronic documentation framework.

One of the most important findings from this work was the identification of factors that may be associated with medication risk during transitions of care. These factors occur at the resident level (e.g., advanced age, polypharmacy, frequent hospitalizations, cognitive impairment) and system level (e.g., electronic health record and pharmacy software used across care settings, interoperability, medication documentation).

The project’s electronic documentation framework has been designed to include the clinical requirements, standardized data elements and workflow needed to systematically capture transition-related medication incidents and near-misses. The immediate priority is a consistent, high-quality approach to data collection.

Once that foundation is in place and larger datasets become available, future research could assess and validate potential predictive variables and explore whether a practical risk-stratification approach could help pharmacists identify residents who may require enhanced medication reconciliation and oversight during transitions. Predictive modelling is a longer-term research objective that would require additional research, an appropriately sized dataset, validation, collaboration with relevant stakeholders, and appropriate funding.

Five years from now, what is your vision for transitions to long-term care?

My vision is that transitions become significantly more connected, proactive, and data informed. The goal is not simply to catch more errors. It is to build a healthcare system that prevents more of them from occurring in the first place.

Internationally, there is growing recognition that medication continuity must become a standard component of safe healthcare delivery. Residents and families should experience transitions as coordinated journeys rather than fragmented handoffs. Pharmacists are uniquely positioned to connect patients, information, and accountability across transitions of care, and I believe their role will continue to grow.