Malpas Pharmacy Newport Discharge Medicines Review


During a stay in hospital, a patient’s medicines may be changed. Studies show that many patients may experience an error or problem with their medicines after they have been discharged.

In 2009 the Care Quality Commission (CQC) published a report examining the arrangements organisations had in place to ensure the safety of patients who had been discharged from hospital with a change of medication. The CQC identified that:

  • Information shared between healthcare providers when a patient moves between sectors is often incomplete and not shared in timely enough fashion.
  • GP’s do not routinely review medication with a patient following discharge, making it more difficult for patients to manage their medicines appropriately.

Improved medicines management post discharge has been cited as one means of improving the transfer of information between secondary and primary care.

The transfer of patients and their medicines between care settings can lead to:

  • Misinterpretation of transferred information
  • Unintended changes in medication
  • Intended changes in medication not being acted upon (e.g. changes in dose or formulation)
  • The continuation of medication that had been stopped prior to the transfer

Problems may arise when discharge information is either late or incomplete. A survey by the NHS Alliance reported 39% of practices reported instances where this failing had directly compromised patient safety. Another study found that when changes were made to patients’ medication during emergency admission to hospital, almost a third of patients were readmitted within two weeks of discharge – they had reverted to pre-admission medication because repeat prescriptions were not amended.


The service will comprise a two-part intervention by the patient’s community pharmacist. The first part will require community pharmacists to check that the medicines prescribed in one care setting (e.g. in hospital) match those prescribed by the GP when the patient returns to their home. If there are discrepancies the pharmacist will have to raise these with the GP. The second part will provide the opportunity for the patient and pharmacist to have a discussion to establish a picture of the patient’s use of their medicines. Where discrepancies were identified at the first stage this will provide an opportunity to ensure they have been rectified. The review will also help patients understand their therapy and it will identify any problems they are experiencing along with possible solutions.


The service should:
Aims and Intended Outcomes The service should:
a) Contribute to a reduction in risk of medication errors and adverse drug events by increasing the availability of accurate information about a patient’s medicines
b) Improve communication between healthcare professionals and others involved in the transfer of patient care, and patients and their carers
c) Increase patient involvement in their own care by helping them to develop a better understanding of their medicines
d) Reduce the volume of medicines that are being wasted when unnecessary, or duplicated prescriptions are dispensed
e) Contribute to avoiding medicines-related admission to hospital or care homes which can occur when un-reconciled medicines lead to prescribing or medicines administration errors
f) Better use the skills of pharmacists, recognising the contribution that they can make in optimising medicines use. *