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Medicines reconciliation in primary care: a study evaluating the quality of medication-related information provided on discharge from secondary care
  1. Chetan Shah1,
  2. Jane Hough2,
  3. Yogini Jani3,4
  1. 1 Pharmacy Department, Hertfordshire Partnership University NHS Foundation Trust, Hertfordshire, UK
  2. 2 Medicines Use and Safety, NHS Specialist Pharmacy Service, London, UK
  3. 3 UCLH NHS Foundation Trust, UCL School of Pharmacy, London, UK
  4. 4 UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
  1. Correspondence to Chetan Shah, Pharmacy Department, Hertfordshire Partnership University NHS Foundation Trust, Hertfordshire WD7 9FB, UK; chetanshah{at}


Objectives Medicines reconciliation is an effective way of reducing errors at transitions of care. Much of the focus has been on medicines reconciliation at point of admission to hospital. Our objective was to evaluate medicines reconciliation after discharge from hospital by assessing the quality of information regarding medicines within discharge summaries and determining whether the information provided regarding medicines changes were acted on within 7 days of receiving the discharge information.

Methods A retrospective collaborative evaluation of medicines-related discharge information by Clinical Commissioning Group (CCG) pharmacists using standardised data collection tools. Outcomes of interest included compliance with national minimum standards for medication-related information on discharge summaries, such as allergies, changes to medication regimen, minimum prescription standards, for example, dose, route, formulation and duration, and medicines reconciliation by the primary care team. Data were analysed centrally.

Results 43 CCGs covering each of the four National Health Service regions in England participated in the study and submitted data for 1454 patients and 10 038 prescribed medicines. The majority of medication details were stated in accordance with standards with the exception of indication (11.7% compliance), formulation (60.3% compliance) and instructions of ongoing use (72.5% compliance). Documentation about changes was poor: 1550/3164 (49%) newly started medicines, 186/477 (39%) dose changes and 420/738 (57%) stopped medicines had a reason documented. Changes were not acted on within 7 days of receiving the discharge information for 12.5% of patients.

Conclusions Our evaluation revealed overall good compliance with discharge medication documentation standards, but a number of changes to medicines during hospitalisation were not fully communicated or documented on the discharge summary or actioned in the general practice after discharge.

  • pharmacy management (organisation, financial)
  • quality management
  • medical errors
  • clinical audit
  • dispensing forms

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