International Journal of Clinical Pharmacy

, Volume 39, Issue 2, pp 394–402 | Cite as

Improving communication of medication changes using a pharmacist-prepared discharge medication management summary

  • Choon Ean Ooi
  • Olivia Rofe
  • Michelle Vienet
  • Rohan A. ElliottEmail author
Research Article


Background Discontinuity of care between hospital and primary care is often due to poor information transfer. Medication information in medical discharge summaries (DS) is often incomplete or incorrect. The effectiveness and feasibility of hospital pharmacists communicating medication information, including changes made in the hospital, is not clearly defined. Objective To explore the impact of a pharmacist-prepared Discharge Medication Management Summary (DMMS) on the accuracy of information about medication changes provided to patients’ general practitioners (GPs). Setting Two medical wards at a major metropolitan hospital in Australia. Method An intervention was developed in which ward pharmacists communicated medication change information to GPs using the DMMS. Retrospective audits were conducted at baseline and after implementation of the DMMS to compare the accuracy of information provided by doctors and pharmacists. GPs’ satisfaction with the DMMS was assessed through a faxed survey. Main outcome measure Accuracy of medication change information communicated to GPs; GP satisfaction and feasibility of a pharmacist-prepared DMMS. Results At baseline, 263/573 (45.9%) medication changes were documented by doctors in the DS. In the post-intervention audit, more medication changes were documented in the pharmacist-prepared DMMS compared to the doctor-prepared DS (72.8% vs. 31.5%; p < 0.001). Most GPs (73.3%) were satisfied with the information provided and wanted to receive the DMMS in the future. Completing the DMMS took pharmacists an average of 11.7 minutes. Conclusion The accuracy of medication information transferred upon discharge can be improved by expanding the role of hospital pharmacists to include documenting medication changes.


Australia Continuity of patient care Medication changes Medication management Patient transfer Pharmacists 



We gratefully acknowledge The Royal Melbourne Hospital for participating and providing support during the study period, Kirstie Galbraith (Monash University) for her support and advice in planning the study, and the pharmacists and general practitioners involved in the study.


No funding was received for this research.

Conflicts of interest

The authors have no conflicts of interest to declare.


  1. 1.
    Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646–51.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;141(7):533–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Bergkvist A, Midlöv P, Höglund P, Larsson L, Bondesson Å, Eriksson T. Improved quality in the hospital discharge summary reduces medication errors—LIMM: Landskrona Integrated Medicines Management. Eur J Clin Pharmacol. 2009;65(10):1037–46.CrossRefPubMedGoogle Scholar
  4. 4.
    Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. J Am Med Assoc. 2007;297(8):831–41.CrossRefGoogle Scholar
  5. 5.
    Glintborg B, Andersen SE, Dalhoff K. Insufficient communication about medication use at the interface between hospital and primary care. Qual Saf Health Care. 2007;16(1):34–9.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Grimes T, Delaney T, Duggan C, Kelly JG, Graham IM. Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care. Ir J Med Sci. 2008;177(2):93–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Shakib S, Philpott H, Clark R. What we have here is a failure to communicate! Improving communication between tertiary to primary care for chronic heart failure patients. Intern Med J. 2009;39(9):595–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Duggan C, Feldman R, Hough J, Bates I. Reducing adverse prescribing discrepancies following hospital discharge. Int J Pharm Pract. 1998;6:77–82.CrossRefGoogle Scholar
  9. 9.
    Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. Br Med J. 2000;320(7237):791–4.CrossRefGoogle Scholar
  10. 10.
    Alderton M, Callen J. Are general practitioners satisfied with electronic discharge summaries? Health Inf Manag J. 2007;36(1):7–12.Google Scholar
  11. 11.
    Callen JL, Alderton M, McIntosh J. Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries. Int J Med Inf. 2008;77(9):613–20.CrossRefGoogle Scholar
  12. 12.
    Maslove DM, Leiter RE, Griesman J, Arnott C, Mourad O, Chow CM, et al. Electronic versus dictated hospital discharge summaries: a randomized controlled trial. J Gen Intern Med. 2009;24(9):995–1001.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Callen J, McIntosh J, Li J. Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries. Int J Med Inf. 2010;79(1):58–64.CrossRefGoogle Scholar
  14. 14.
    Lehnbom EC, Raban MZ, Walter SR, Richardson K, Westbrook JI. Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries. Health Inf Manag J. 2014;43(3):4–12.Google Scholar
  15. 15.
    Mills PR, Weidmann AE, Stewart D. Hospital discharge information communication and prescribing errors: a narrative literature overview. Eur J Hosp Pharm. 2016;23(1):3–10.CrossRefGoogle Scholar
  16. 16.
    Grimmsmann T, Schwabe U, Himmel W. The influence of hospitalisation on drug prescription in primary care: a large-scale follow-up study. Eur J Clin Pharmacol. 2007;63:783–90.CrossRefPubMedGoogle Scholar
  17. 17.
    Carter BL, Farris KB, Abramowitz PW, Weetman DB, Kaboli PJ, Dawson JD, et al. The Iowa continuity of care study: background and methods. Am J Health Syst Pharm. 2008;65(17):1631–42.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Halasyamani L, Kripalani S, Coleman E, Schnipper J, van Walraven C, Nagamine J, et al. Transition of care for hospitalized elderly patients—Development of a discharge checklist for hospitalists. J Hosp Med. 2006;1(6):354–60.CrossRefPubMedGoogle Scholar
  19. 19.
    Karapinar F, van den Bemt PM, Zoer J, Nijpels G, Borgsteede SD. Informational needs of general practitioners regarding discharge medication: content, timing and pharmacotherapeutic advice. Pharm World Sci. 2010;32(2):172–8.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Kliethermes MA. Continuity of care: the significance of the pharmacist’s role. Am J Health Syst Pharm. 2003;60(17):1787–90.PubMedGoogle Scholar
  21. 21.
    Norris CM, Thomas V, Calvert PS. An audit to evaluate the acceptability of pharmacist electronically prescribing discharge medication and providing information to general practitioners. Pharm J. 2001;267:857–9.Google Scholar
  22. 22.
    Young A, Horsely J. A complete service model of medicines management offers patients continuity of care. Pharm Pract. 2007;17(5):168–72.Google Scholar
  23. 23.
    de Clifford J, Lam S, Leung B. Evaluation of a pharmacist-initiated e-script transcription service for discharged patients. J Pharm Pract Res. 2009;39:39–42.CrossRefGoogle Scholar
  24. 24.
    Hong J, Chen C, Galbraith K. Documentation of medication changes for patients discharged to aged care facilities—How well is it done?. Royal Melbourne Hospital: Pharmacy Department; 2006.Google Scholar
  25. 25.
    Carter MK, Allin DM, Scott LA, Grauer D. Pharmacist-acquired medication histories in a university hospital emergency department. Am J Health Syst Pharm. 2006;63(24):2500–3.CrossRefPubMedGoogle Scholar
  26. 26.
    Reeder TA, Mutnick A. Pharmacist-versus physician-obtained medication histories. Am J Health Syst Pharm. 2008;65(9):857–60.CrossRefPubMedGoogle Scholar
  27. 27.
    Steurbaut S, Leemans L, Leysen T, De Baere E, Cornu P, Mets T, et al. Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home. Ann Pharmacother. 2010;44(10):1596–603.CrossRefPubMedGoogle Scholar
  28. 28.
    Nazareth I, Burton A, Shulman S, Smith P, Haines A, Timberall H. A pharmacy discharge plan for hospitalized elderly patients- a randomized controlled trial. Age Ageing. 2001;30(1):33–40.CrossRefPubMedGoogle Scholar
  29. 29.
    Beauchesne M, Nenciu LM, Dinh T, Tassé M, Fillion A, Labrecque M, et al. Active communication of a pharmacy discharge plan for patients with respiratory diseases: a pilot study. J Pharm Technol. 2007;23(2):67–74.CrossRefGoogle Scholar
  30. 30.
    Bolas H, Brookes K, Scott M, McElnay J. Evaluation of a hospital-based community liaison pharmacy service in Northern Ireland. Pharm World Sci. 2004;26(2):114–20.CrossRefPubMedGoogle Scholar
  31. 31.
    Brookes K, Scott MG, McConnell JB. The benefits of a hospital based community services liaison pharmacist. Pharm World Sci. 2000;22(2):33–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Stowasser DA, Collins DM, Stowasser M. A randomised controlled trial of medication liaison services—Patient outcomes. J Pharm Pract Res. 2002;32:133–40.CrossRefGoogle Scholar
  33. 33.
    Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother. 2004;2(4):257–64.CrossRefPubMedGoogle Scholar
  34. 34.
    Vuong T, Marriott JL, Kong DCM, Siderov J. Implementation of a community liaison pharmacy service: a randomised controlled trial. Int J Pharm Pract. 2008;16:127–35.CrossRefGoogle Scholar
  35. 35.
    Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166(5):565–71.CrossRefPubMedGoogle Scholar
  36. 36.
    Yu K, Nguyen A, Shakib S, Doecke CJ, Boyce M, March G, et al. Enhancing continuity of care in therapeutics: development of a post-discharge home medicines review model. J Pharm Pract Res. 2007;37:22–6.CrossRefGoogle Scholar
  37. 37.
    Bollella G, Angley MT, Pink JA, Caird CJ, Goldsworthy SJ. Optimal level of liaison pharmacist intervention to facilitate a post-discharge home medicines review. J Pharm Pract Res. 2008;38:107–10.CrossRefGoogle Scholar
  38. 38.
    Walker PC, Bernstein SJ, Jones JN, Piersma J, Kim HW, Regal RE, et al. Impact of a pharmacist facilitated hospital discharge program: a quasi-experimental study. Arch Intern Med. 2009;169(21):2003–10.CrossRefPubMedGoogle Scholar
  39. 39.
    McMillan TE, Allan W, Black PN. Accuracy of information on medicines in hospital discharge summaries. Intern Med J. 2006;36(4):221–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Macaulay EM, Cooper GG, Engeset J, Naylor AR. Prospective audit of discharge summary errors. Br J Surg. 1996;83(6):788–90.CrossRefPubMedGoogle Scholar
  41. 41.
    Coombes ID, Stowasser DA, Coombes JA, Mitchell C. Why do interns make prescribing errors? A qualitative study. Med J Aust. 2008;188(2):89–94.PubMedGoogle Scholar
  42. 42.
    Bayley KB, Savitz LA, Maddalone T, Stoner SE, Hunt JS, Wells R. Evaluation of patient care interventions and recommendations by a transitional care pharmacist. Ther Clin Risk Manag. 2007;3(4):695–703.Google Scholar
  43. 43.
    Stuchbery P, Kong DC, DeSantis GN, Lo SK. Clinical pharmacy workload in medical and surgical patients: effect of patient partition, disease complexity and major disease category. Int J Pharm Pract. 2010;18(3):159–66.PubMedGoogle Scholar
  44. 44.
    Bonevski B, Magin P, Horton G, Foster M, Girgis A. Response rates in GP surveys: trialling two recruitment strategies. Aust Fam Physician. 2011;40(6):427–30.PubMedGoogle Scholar
  45. 45.
    Australian Digital Health Agency [Internet]. Sydney: Commonwealth of Australia; c2010–2016 (updated 2016; cited 2016 June 20). (2016).

Copyright information

© Springer International Publishing 2017

Authors and Affiliations

  1. 1.Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityParkvilleAustralia
  2. 2.Eastern HealthBox HillAustralia
  3. 3.Austin HealthHeidelbergAustralia

Personalised recommendations