Imagine nearly one in four elderly patients missing or receiving delayed doses of their critical medications when transitioning from hospitals to aged care facilities. It’s a startling reality that highlights significant gaps in our healthcare system. But here’s where it gets even more concerning: these disruptions aren’t just inconvenient—they can have serious health consequences, especially for those on high-risk medications like opioids, anticoagulants, or insulin. So, what’s causing this issue, and how can we fix it?
Recent research led by Adjunct Associate Professor Rohan Elliott from Austin Health’s Pharmacy Department sheds light on this problem. The team reviewed 397 patient cases from 11 Victorian hospitals, focusing on the 48 hours after hospital discharge. Their findings? A staggering 23% of patients experienced missed or delayed doses. Of these, 5% missed high-risk medications, while 13% missed moderate-risk ones, such as antimicrobials and non-opioid painkillers. And this is the part most people miss: even small disruptions in medication continuity can lead to complications, hospitalizations, or worse.
The study identified key factors that could reduce these risks. For instance, when hospitals provided discharge medications in their original packaging along with an Interim Medication Administration Chart (IMAC), and when community pharmacies delivered repackaged medications on the day of discharge, the likelihood of missed doses decreased significantly. However, only 52% of patients had their aged care medication charts updated on the day of transfer, and just 46% received updated medications from their community pharmacy in time.
Here’s a surprising twist: having a GP or locum complete patients’ medication charts on the day of discharge actually increased the risk of missed doses. Why? GPs are often unavailable until later in the day, leaving a critical gap in the transition process. This raises a thought-provoking question: Are we over-relying on GPs in a system that needs more streamlined, collaborative solutions?
The researchers suggest that hospitals and aged care facilities should be encouraged to adopt IMACs routinely, ensuring timely and safe medication administration. However, they also point out a glaring issue: a lack of clear guidance and standardization from state and federal governments, as well as health and aged care bodies. Without consistent procedures, widespread implementation remains a challenge.
Another bold recommendation? Hospitals should be equipped to provide up to seven days of interim medication supply, aligned with a seven-day IMAC, to bridge the gap between discharge and stable care. With a median time of less than three hours from discharge to the first required dose, this could be a game-changer for continuity.
But here’s the controversial part: While these solutions seem straightforward, they require significant systemic changes. Are healthcare providers, policymakers, and funding bodies ready to prioritize this issue? Or will it remain a silent crisis affecting our most vulnerable population?
The study calls for urgent action to address these barriers, but the question remains: What will it take to make medication continuity a non-negotiable standard of care? Let’s open the floor for discussion—do you think these recommendations are feasible, or are there deeper issues at play? Share your thoughts in the comments below.
For those eager to dive deeper, the full paper is available HERE. This article was originally shared with Pharmacy Daily subscribers on 10 February 2026. To read the full newsletter, CLICK HERE or view the embedded issue below.
