Medicines Reconciliation in Primary Care: quality of information provided on discharge summaries

Nicola Wake, Specialist Pharmacist: Lead Medication Safety, Specialist Pharmacy ServiceExample from Specialist Pharmacy Service Medicines Use and Safety TeamPublished
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Summary of the example

An England wide collaborative audit, co-ordinated by the SPS Medicines Use and Safety team, assessing the quality of medication related information provided when transferring patients from secondary care (acute, mental health and community services) to primary care, showed that communication of this information remains problematic and requires improvement.

Why we think it’s important

Medicines reconciliation is recognised as a process that supports patient safety however the majority of the focus to date has been targeted on medicines reconciliation on admission to hospital.  Evidence and guidance indicates action is required at all transitions of care.  Medicines reconciliation when patients transfer into primary care has not been examined at scale and this is the first England wide audit of patient discharge summaries.

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Aims and objectives of the work

To evaluate the quality of medication related information provided when transferring patients from secondary to primary care and the subsequent medicines reconciliation in primary care.


  • To assess the quality of information regarding medicines within discharge summaries provided by secondary care (acute, mental health and community services)
  • To determine whether GPs correctly acted upon the information provided within seven days of receiving the discharge information


The collaborative evaluation used retrospective review of discharge information by 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 e.g. dose, route, formulation and duration. CCG pharmacists were requested to reconcile medicines between the discharge summary and the pre-admission list on the GP system and record any unintended discrepancies that they identified and document whether the GP had implemented any recommendations or changes from secondary care, and any errors with potential for harm.  Data was analysed centrally at patient level for discharge summary documentation standards, and medicine level for prescribing standards.

Key findings

43 CCGs across the four NHS regions participated in the study.  A total of 1454 discharge summaries and 10,0038 prescribed medicines (mean = 6.9 medicines/ patient) were reviewed.  The median length of inpatient stay was four days (range 0-208 days) and the majority (78.6%) of patients audited were unplanned admissions.

In general the discharge summary arrived with the GP on the day of patient discharge, although there were some outliers with one discharge summary taking 38 days to arrive.

The majority of medication details were stated with the exception of indication (11.7% medicines), formulation (60.3%) and instructions of ongoing use (72.5%).

Documentation about changes was poor, however 1550/3164 (49%) newly started medicines, 186/477 (39%) dose changes, and 420/738 (57%) had a reason documented.

Changes were not acted upon within seven days of receiving the discharge information for 12.5% of patients.

Recommendations made by the authors to improve safety at transitions of care include:

  • CCGs and secondary care providers should collaborate to review local hospital discharge templates to ensure they meet the needs of all involved
  • Secondary care providers should utilise Summary Care Records to ensure medicines reconciliation at admission is robust
  • GP practices should have clear processes in place on how information provided on discharge summaries/prescriptions is managed on receipt
  • Consideration should be given to designating the responsibility of reconciling medicines post discharge from hospital to the growing number of clinical pharmacists employed within GP practices


The audit protocol and tool, and the SPS medicines reconciliation best practice resource and toolkit can be found in the links below




National guidance, data and publications

NICE and NPSA issued guidance to improve medicines reconciliation at hospital admission in 2007.  In 2009, a report by the CQC stated that acute Trusts needed to improve the information they provide on changes to medication at discharge.

NICE Medicines Optimisation Guidance, issued in 2015, made recommendations on sharing relevant information about medicines when people move from one care setting to another, and on the medicines reconciliation process, including the recommendation that in primary care medicines reconciliation is carried out for all people who have been discharged from hospital or another care setting as soon as practically possible, before a prescription or new supply of medicine is issued and within one week of the GP practice receiving the information.