Ethical case discussions among the care team took place regularly (44 case discussions between January 2011 and June 2012). The duration of these discussions ranged from 30 to 60 min. On average 6.2 persons took part, including 2.7 nurses and 3.2 physicians. Of the 41 patients (16 female, 25 male) for whom a discussion was carried out, 23 died during the continued hospital stay. The respondents (response rate 52 %) assessed the benefit for patients and team as high (slightly higher benefit for physicians than nurses) and 55 % of physicians and 71 % of nurses perceived a reduction in the burden of decision-making in difficult cases due to the case discussions. All physicians and 66 % of the nurses reported an improvement in the cooperation between the professional groups and 80 % of the nurses and more than half of the physicians noticed an increase in their own ethical competence. Conclusion Documenting medication changes and their reasons is a manual process, and therefore can be time consuming, especially when a patient has been in hospital for an extended period and/or has had multiple medication changes sometimes made by multiple medical teams. This, in part, may explain why there is often incomplete documentation of medication changes [ 10]. Ward-based pharmacists in Australia and other countries routinely perform medication reconciliation on discharge, which includes identifying medication changes and communicating them to the patient [ 10]. Yet this pharmacist-generated information is not routinely shared with primary care physicians. A study by Ooi et al. [ 24] reported that the option to receive a pharmacist-prepared summary of medication changes made in the hospital was an approach that many primary care physicians preferred and were satisfied with. In our study, when pharmacists contributed to discharge summaries, around 80% of clinically significant medication changes were stated in the EDS, and around two-thirds were both stated and explained. This is a major improvement compared to our baseline data, and other studies evaluating discharge summaries prepared without pharmacist involvement, where around 50% or fewer in-hospital medication changes are typically noted or explained [ 8, 9, 10, 16, 27].

Tanner S, Albisser Schleger H, Meyer-Zehnder B et al (2014) Klinische Alltagsethik – Unterstützung im Umgang mit moralischem Distress? Evaluation eines ethischen Entscheidungsfindungsmodells für interprofessionelle klinische Teams. Med Klin Intensivmed Notfmed. DOI 10.1007/s00063-013-0327-y This was a pre- and post-intervention study that used retrospective medical record audits to assess the accuracy of EDSs for random samples of patients discharged from inpatient wards at a major public teaching hospital in Melbourne, Australia, at three time points: 2014, 2015 and 2017. The methods used for the audits in this study were the same as those used in a previous hospital-wide audit of EDSs at our hospital [ 10]. Accanto Health, the parent company of The Emily Program, Veritas Collaborative, and Gather Behavioral Health, is the sole planner and provider of all courses, content, and continuing education credits. This program is made possible with support from The Emily Program Foundation.Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 2002;359(9315):1373–8. Heinke W, Dunkel P, Brahler E et al (2011) Burn-out in der Anästhesie und Intensivmedizin – Gibt es ein Problem in Deutschland? Anaesthesist 60:1109–1118

Accanto Health is approved by the American Psychological Association to sponsor continuing education for psychologists. Accanto Health maintains responsibility for this program and its content. This program provides 2.0 continuing education credits. Despite the clear benefits of this intervention, it is important to recognise the additional workload and time implications for pharmacists. This highlights the importance of an adequate hospital pharmacist workforce and resources to sustain it. Pharmacists reported that verifying and contributing to the EDS required, on average, 5 min of their time, and up to 16 min for more complex discharges. When patient turnover was high, reviewing and verifying discharge summaries on top of existing duties, without any additional staffing resource, was difficult for pharmacists in our study, as evidenced by the fact that fewer than 50% of EDSs were verified in the 2015 post-intervention audit. Although the intervention only required a few minutes per patient, when a pharmacist is managing up to 10 discharges per day this is a significant additional workload. In the aged care wards, where length of stay was longer, and hence the number of discharges per day was lower, around two-thirds of EDSs were verified and the pharmacists were able to sustain that level of contribution when it was incorporated into usual care. The intervention was not able to be sustained beyond the pilot intervention period in wards where turnover was high.Albisser Schleger H, Mertz M, Meyer-Zehnder B, Reiter-Theil S (2012) Klinische Ethik-METAP – Leitlinie für Entscheidungen am Krankenbett. Springer, Berlin Heidelberg New York Tokio This study demonstrated the positive impacts of pharmacist–physician collaboration in the preparation of medical discharge summaries. Significant improvements were observed in both medication list accuracy and medication change information when ward-based pharmacists reviewed, contributed and verified medication information in the EDS. Importantly, in the four wards where the intervention was incorporated into usual care, benefits were sustained two years later. This finding is important because, in contrast to the first post-intervention audit where there was a project officer supporting the intervention, the benefits observed two years later were a reflection of usual ward pharmacist practice without additional support. Furthermore, the pharmacists at that time did not know the EDS would be audited, which adds strength to the findings because there was no potential bias from a Hawthorn effect. Reiter-Theil S (2005) Klinische Ethikkonsultation – eine methodische Orientierung zur ethischen Beratung am Krankenbett. Schweiz Arzteztg 86:346–351

Qaseem A, Forland F, Macbeth F et al (2012) Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med 156:525–531 Royal College of Physicians. E-discharge summaries learning resourceproject. Final report v1.1. London: Royal College of Physicians. 2019. Example: (photons AND downconversion) - pump [search contains both "photons" and "downconversion" but not "pump"]Poncet MC, Toullic P, Papazian L et al (2007) Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med 175:698–704 Marshall WA, Tanner JM (June 1969). "Variations in pattern of pubertal changes in girls". Arch. Dis. Child. 44 (235): 291–303. doi: 10.1136/adc.44.235.291. PMC 2020314. PMID 5785179. Reiter-Theil S, Mertz M, Schurmann J et al (2011) Evidence – competence – discourse: the theoretical framework of the multi-centre clinical ethics support project METAP. Bioethics 25:403–412 Tanner, the author of the classification system, has argued that age classification using the stages of the scale misrepresents the intended use. Tanner stages do not match with chronological age, but rather maturity stages and thus are not diagnostic for age estimation. [13] Accanto Health has been approved by NBCC as an Approved Continuing Education Provider, ACEP no.7166. Programs that do not qualify are clearly identified. Accanto Health is solely responsible for all aspects of the programs.