Exploring pharmacist involvement in the discharge medicines reconciliation process and information transfer to primary care: an observational study

Abstract

Background Medication errors can occur because of incomplete or poorly communicated information at the transition from hospital to community. Following an audit in 2016, a project was undertaken to determine if pharmacists could improve the quality of medication information in discharge summaries by introducing a discharge medication reconciliation process. Pharmacists recorded any changes to the patient’s medication in the electronic prescribing system during their inpatient stay and summarised these changes on discharge. Objective To compare medication information in discharge summaries with recognised standards for the clinical structure and content of patient records, and to assess the impact of the pharmacist process on compliance with certain elements of these standards. Setting A 750 bed teaching district general hospital in England. Method A retrospective observational study examining all patient discharge summaries over a 1 week period for compliance to national standards. Main outcome measure The main outcome measures were compliance with standards for medication started, stopped or changed in hospital and any differences between extent of recording this information by doctors and pharmacists. Results Data were collected and analysed for 243 patients, of whom 94 (38.7%) attracted a discharge medicines reconciliation process by a pharmacist. Discharge summaries were compliant with basic standards for changed medication in 42% of patients or 51.4% with the input of a pharmacist. This increase of 9.4% was statistically significant (p = 0.0365). At an enhanced level, pharmacists increased compliance from 39.1 to 46.5%, this did not represent a significant increase (p = 0.0989). Conclusion Pharmacists undertaking a discharge medication reconciliation process significantly improves the quality of discharge summaries.