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Medicines reconciliation

Poor communication about medicines when patients transfer from secondary to primary care, audit reveals

Results of an audit into medicines reconciliation highlight the potential of pharmacists working in GP surgeries.

Hospital doctor and nurse talking to a discharge coordinator on a ward

Source: Mark Thomas / Science Photo Library

The audit reveals that some 79% of the patients started at least one new medicine when they were discharged from hospital, but the reason for the new drug only appeared in 49% of the discharge notes

Information on medicines is not being passed on effectively from hospitals to GPs when patients are discharged, an audit has found. 

Some 47 clinical commissioning groups in England took part in the audit of medicines information, which appears on a patient’s hospital discharge summary note and is sent to the GP. 

The results indicate that there is a need for “significant improvement” in communication about medicines changes when patients are discharged from hospital, according to the report. 

“GP practices need clear processes in place on how information provided on the discharge summary… is managed once received, including who is responsible for reviewing medicines on discharge summaries and who updates the GP prescribing system,” the report says. “Consideration should be given to the role of clinical pharmacists in GP practices in reconciling medicines post discharge from secondary care.” 

The audit – designed to evaluate the success of medicines reconciliation between primary and secondary care – involved 1,454 patients aged 72 years on average who were prescribed more than 10,000 medicines. The average number of medicines prescribed per patient on discharge was 6.9. 

Some 79% of the patients started at least one new medicine when they were discharged from hospital, but the audit reveals that the reason for the new medicine only appeared in 49% of the discharge notes. 

A total of 27% of patients had a medicine discontinued in hospital but the reason behind this decision only appeared in 57% of patient notes that were sent to GPs. 

Nearly a quarter – 23% – of patients had doses of their medicines changed while in hospital but the reason for the change was only given in 39% of discharge notes. 

The audit also found that 5.5% of actions required by the patient’s GP on discharge were carried out incorrectly. 

The audit was commissioned by the NHS Specialist Pharmacy Service, which has a role to promote medicines optimisation across the NHS in England. 

The report calls for improved collaboration between clinical commissioning groups and hospitals to ensure that hospital discharge templates reflect the professional standards about medicines transfer information set by the Royal Pharmaceutical Society and the Academy of Royal Colleges. 

Commenting on the audit, Sandra Gidley, chair of the RPS’s English Pharmacy Board, says the findings “come as no surprise”. 

Sandra Gidley, chair of the English Pharmacy Board of the Royal Pharmaceutical Society (RPS)

Source: MAG / The Pharmaceutical Journal

Sandra Gidley, chair of the RPS’s English Pharmacy Board, says community pharmacists spend many hours trying to get medicines right for patients and poor discharge summaries, sometimes differing from the take home medicines, are not uncommon

“Any pharmacist who regularly has to deal with patients who have recently been discharged from hospital will have numerous stories to tell, although it is fair to say that there are geographic differences in the quality of information being provided on a discharge summary.” 

Gidley points out that community pharmacists and pharmacy staff spend many hours trying to get medicines right for patients and poor discharge summaries, sometimes differing from the take home medicines, are not uncommon, as highlighted by the report.

“Of more concern is that the patients themselves are often confused as they are not always aware of the changes or the reasons for them,” she says. “Ensuring seamless transfer of care is a clear role for practice pharmacists and one where there is a real benefit to patients. However, access to electronic health records is also crucial, along with a clear need to reasons for changes to medication.” 

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2016.20201606

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Supplementary images

  • Hospital doctor and nurse talking to a discharge coordinator on a ward
  • Sandra Gidley, chair of the English Pharmacy Board of the Royal Pharmaceutical Society (RPS)

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