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Pharmacist contributions to ensuring safe and accurate transfer of written medicines-related discharge information: lessons from a collaborative audit and service evaluation involving 45 hospitals in England


Objectives To audit the quality of written hospital discharge prescriptions and quantify and evaluate pharmacy contributions to ensuring discharge medication information is accurate and complete.

Methods A tool was developed and piloted to audit discharge prescription information against best practice guidance. Simultaneously, pharmacist contributions to discharge prescription accuracy and completeness were recorded, classified and rated for potential clinical impact. Results were analysed according to four variables: care area; emergency or elective admission; type of prescription; place of screening.

Results 2071 discharge prescriptions were audited in 45 trusts. 32% of prescriptions met the audit definition of legal and unambiguous. Pharmacists made an average of 1.4 contributions per audited prescription to ensure accuracy and completeness of information. 33% of these contributions were judged to have averted moderate or severe patient harm. Minor variations in error rates and potential for clinical impact were seen across the variables studied. Organisations using fully electronic prescribing systems had error and omission rates similar to those producing electronic discharge prescriptions from handwritten charts. Pharmacy-led medicines reconciliation at admission supported the identification of issues requiring resolution in 23% of audited prescriptions. Pharmacy departments screened prescriptions for approximately 50% of patients recorded as discharged.

Conclusions Two-thirds of audited discharge prescriptions were inaccurate or incomplete prior to pharmacy screening. Clinical screening by pharmacists contributes significantly to patient safety and is supported by pharmacy-led medicines reconciliation at admission. Discharge prescriptions released without a pharmacy screen could pose a risk to the patient.

  • computer assisted prescribing

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