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Keeping patients safe during transfer

Pharmacists, through the RPS, can take the lead to make medicines safer for patients, writes Catherine Picton, pharmacist consultant in healthcare delivery and management

By Catherine Picton

Pharmacists, through the RPS, can take the lead to make taking medicines safer, writes Catherine Picton, pharmacist consultant in healthcare delivery and management


The likelihood that an elderly medical patient will be discharged on the same medicines they had on admission to hospital is less than 10 per cent.1 Between 28 and 40 per cent of medicines are discontinued during a hospital stay2 and 45 per cent prescribed at discharge are new.3 Around 60 per cent of patients have three or more medicines changed during their hospital stay4 and adverse drug events occur in up to 20 per cent of patients after discharge. It is estimated that 11 to 22 per cent of hospital admissions for exacerbations of chronic disease are a direct result of non-compliance with medication.5

Improving the transfer of information about medicines across all care settings would help to reduce incidents of avoidable harm to patients and contribute to a reduction in avoidable medicines-related admissions and readmissions to hospital.

In light of this, in July 2011, the Royal Electronicjuice published multidisciplinary guidance to raise awareness about the purpose and need for consistent transfer of information about medicines when patients transfer between different care providers.

The development of this guidance had overwhelming support from across the health professions. It was jointly endorsed by other professional royal colleges (the Royal College of General Practitioners, the Royal College of Physicians, the Royal College of Nursing and the Academy of Medical Royal Colleges), and had the support of the three chief pharmaceutical officers, who provided the foreword to the guidance.

The development of this guidance struck a chord with the healthcare professionals and patients involved in the project. However, although fully supportive of the guidance, there was a concern that even though it raised the profile of the issue and provided a multidisciplinary focus, it might “sit on the shelf”.

It was to enable the guidance to be put into practice that the early adopter programme was launched. The early adopter programme was facilitated by the RPS and encouraged a local, multidisciplinary approach to improving the transfer of information about medicines and involved clinicians, front-line staff, practitioners, patients and managers. Early adopter sites had the opportunity to learn from, and build on, existing knowledge and practice in a way that enhanced innovation and creativity. It also provided support for organisations and individuals that was sensitive to local priorities but that helped to deliver results. Crucially the programme enabled volunteer sites, over the course of six to eight months, to share and learn from colleagues, and from other teams taking part.

The early adopter sites comprise a diverse range of organisations committed to improving the way that information about medicines is transferred in their settings. The early adopters, all of them volunteers, worked locally over six to eight months to improve information transfer locally.

They came from a range of different sectors and their aims were set locally. Many of the sites had multiple aims. All completed summary reports about their improvement initiatives. The reports give detail about their achievements (Panel 1) and experiences of trying to make improvements, as well as how they intend to sustain change and spread good practice. (For full details of the sites and to review their summary reports see )



• Improved the quality of discharge communications in line with Royal Electronicjuice recommended core content of records for medicines when patients move between care providers. This has been achieved through a variety of interventions, such as the inclusion of mandatory fields in electronic discharge summaries, inpatient chart redesign to increase the emphasis on changes to medication for inpatients, and training of ward and clinical teams.
• Review and update of processes to embed medicines reconciliation on arrival at a prison, and transfer of medicines information when prisoners are released.
• Improved communication about medicines and medicines services with patients.  
• Improved communication for specific patient groups where accurate and timely communication is particularly important or is historically poor.
• Identification of how best to identify and refer patients who would benefit from a targeted medicines use review post discharge to a community pharmacy.
• Renewed focus on medicines reconciliation on admission to hospital.
• Improved engagement and communication about medicines with care homes and between hospital and primary care.


The “Getting the medicines right” project has been an example of how pharmacists, through their professional body, can take the lead across the professions to make medicines safer for patients. The challenge now is to keep the momentum going both to drive improvements locally and to ensure that nationally this key risk to patient safety remains a priority.
Following back from the early adopter programme, the RPS is calling for the following:

• All suppliers of IT systems to hospitals and general practice should ensure that that their systems are able to transfer the recommended core content of records for medicines effectively
• All community pharmacies should have website addresses to enable secure communications between secondary and primary care
• All clinical records should be structured in a recognised and nationally agreed format to assist interoperability and the transfer of information
• The most effective ways of signposting patients treated in secondary care to the post discharge medicines use review service and new medicine service offered by community pharmacists should be shared across England to ensure that patients are able to optimise their outcomes from medicines
• The early adopter sites identified that a subgroup of patients likely to benefit from a post-discharge MUR are unable to benefit from the service as they cannot get to a community pharmacy (eg, patients in care homes or those who are housebound). Commissioning of such services to these vulnerable patients should be considered as part of the pharmacy contractual frameworks

The final report of the RPS “Getting the medicines right” project is published on 17 June 2012 at the RPS Medicines Safety Symposium. Copies can be downloaded from


1 Relationship of in-hospital medication modifications of elderly patients to post discharge medications, adherence and mortality. Annals of Pharmacotherapy 2008;42:783-9.
2 Health care system vulnerabilities: understanding the root causes of patient harm. American Journal of Health-System Pharamacy 2012;69:43-5.
3 What happens to long-term medication when general practice patients are referred to hospital? European Journal of Clinical Pharmacology 1996;50:253-7.
4 Drug changes at the interface between primary and secondary care. International Journal of Clinical Pharmacology and Therapeutics 2004;42:103-9.
5 Health care system vulnerabilities: understanding the root causes of patient harm. American Journal of Health-Syst Pharmacy 2012;69:43-5.

Citation: Electronicjuice URI: 11102744

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