Safe Discharge Prescriptions- January 2013

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Safe Discharge Prescriptions


Listed below is the high level evidence on Safe discharge prescriptions produced by NICE, SIGN and NHS based organisations. Also included are the European Society guidelines where available. This list is produced and maintained by HEFT Library Services to support VITAL 4 Medics core skills programme developed in the Trust.


HEFT Local Policies

Admissions and Discharges – SharePoint site

Highlights Trusts’ policies; discharge flow chart and bed management procedures.


Map of Medicine (MoM)

Use HEFT Athens ID to login to Map of Medicine.

Map of Medicine is a visual representation of evidence-based, practice –informed pathways on various conditions and treatment options. Prescriptions forms part of the pathways and the evidence links to national guidelines and guidelines from professional bodies related to that specific condition or therapies.


National Guidelines & Non-UK Guidelines (includes Professional Bodies/Associations)

Moving patients, Moving Medicines, Moving Safely: Guidance on Discharge and Transfer Planning

Prepared by The Royal Pharmaceutical Society of Great Britain; The Guild of Hospital Pharmacists; The Pharmaceutical Services Negotiating Committee; The Primary Care Pharmacists’ Association, 2008


The SIGN Discharge Document (Guideline no. 128)

SIGN, June 2012

This replaces SIGN 65. The aim is to present a template for a single discharge document that can be used as both the IDD (in its core format) for every patient on the day of discharge, and as the final discharge summary/ letter (in its extended format) for more complex cases. This update reflects the fact that the production and communication of documents by electronic means within both primary and secondary care is becoming more common.


Discharge planning: a guide

BMJ Learning Module, December 2010

Written by:

Mark Thomas, Niall Ferguson, Natasha Jacques, Liz Lees, and Helen Morant


Ready to Go? Planning the Discharge and the Transfer of Patients from Hospital and Intermediate Care.

Department of Health, March 2010.


Discharge Planning: a summary of DoH guidance Ready to go? Planning the Discharge and the Transfer of patients from Hospital and Intermediate Care

RCN Publishing Essential Guide, Spring 2010.


Achieving timely ‘simple’ discharge from hospital : A toolkit for the multi-disciplinary team

Department of Health, August 2004.

The toolkit focuses on the practical steps that health and social care professionals can take to improve discharge.


Discharge from hospital: pathway, process and practice

Health and Social Care Joint Unit and Change Agent Team, January 2003.

This good practice guidance updates and builds on the Hospital Discharge Workbook published in 1994.


Systematic Reviews – Cochrane Library

Discharge planning from hospital to home

Sasha Shepperd1,*,  Jacqueline McClaran2,  Christopher O Phillips3,  Natasha A Lannin4,  Lindy M Clemson5,  Annie McCluskey6,  Ian D Cameron7,  Sarah L Barras8

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 20 JAN 2010

The aim of this Cochrane Review was to determine the effectiveness of planning the discharge of patients moving from hospital.

NHS Evidence

A Structured Evidence-Based Literature Review on Discharge, Referral and Admission

Australian Commission on Safety and Quality in Health Care (ACSQHC) and New South Wales Health, September 2010

This document provides three structured evidence-based literature reviews on the benefits, enablers, barriers and challenges related to the processes of discharge, referral and admission covering Australian and International published works.


Adherence to emergency department discharge prescriptions

Corinne M. Hohl, Riyad B. Abu-Laban, Jeffrey R. Brubacher, Peter J. Zed, Boris Sobolev, Gina Tsai, BPharm;† Patricia Kretz, Kevin Nemethy, Jaap Bijlsma, Roy A. Purssell,

CJEM 2009;11(2):131-8

Full text is available from here


A clinical audit of the time taken for GP surgeries to receive patients' discharge prescriptions

Original article by: E Ogunbase, N Thomas

Reference: Clinical Pharmacist Apr 2012;4(Suppl.2):S8

Full text of this audit can read on page 8 of the document here


Title: 3D: a tool for medication discharge education.

Citation: Quality & Safety in Health Care, February 2007, vol./is. 16/1(71-6), 1475-3898;1475-3901 (2007 Feb) Author(s): Manning DM, O'Meara JG, Williams AR, Rahman A, Myhre D, Tammel KJ, Carter LC

Abstract: BACKGROUND: At the time of transition from hospital to home, many patients are challenged by multi-drug regimens. The authors' standard patient education tool is a personalised Medication Discharge Worksheet (MDW) that includes a list of medications and administration times. Nonetheless, patient understanding, satisfaction, and safety remain suboptimal. Therefore, the authors designed a new tool: Durable Display at Discharge (3D). Unlike MDW, 3D features (1) space in which a tablet or pill is to be affixed and displayed, (2) trade name (if apt), (3) unit strength, (4) number (and/or fraction) of units to be taken, (5) purpose (indication), (6) comment/caution, (7) larger font, (8) card stock durability and (9) a reconciliation feature.METHODS: The authors conducted an exploratory, randomised trial (n = 138) to determine whether 3D, relative to MDW, improves patient satisfaction, improves patient understanding and reduces self-reported medication errors. Trained survey research personnel, blinded to hypotheses, interviewed patients by telephone 7-14 days after discharge.RESULTS: Both tools were similarly associated with high satisfaction and few self-reported errors. However, 3D subjects demonstrated greater understanding of their medications.CONCLUSIONS: Although both tools are associated with similarly high levels of patient satisfaction and low rates of self-reported medication error, 3D appears to promote patient understanding of the medications, and warrants further study.

Full Text: Available in fulltext at National Library of Medicine

Title: Medication details documented on hospital discharge: Cross-sectional observational study of factors associated with medication non-reconciliation

Citation: British Journal of Clinical Pharmacology, March 2011, vol./is. 71/3(449-457), 0306-5251;1365-2125 (March 2011) Author(s): Grimes T.C., Duggan C.A., Delaney T.P., Graham I.M., Conlon K.C., Deasy E., Jago-Byrne M.-C., O' Brien P.

Abstract: Aims: Movement into or out of hospital is a vulnerable period for medication safety. Reconciling the medication a patient is using before admission with the medication prescribed on discharge, and documenting any changes (medication reconciliation) is recommended to improve safety. The aims of the study were to investigate the factors contributing to medication reconciliation on discharge, and identify the prevalence of non-reconciliation. Methods: The study was a cross-sectional, observational survey using consecutive discharges from purposively selected services in two acute public hospitals in Ireland. Medication reconciliation, potential for harm and unplanned re-admission were investigated. Results: Medication non-reconciliation was identified in 50% of 1245 inpatient episodes, involving 16% of 9569 medications. The majority of non-reconciled episodes had potential to result in moderate (63%) or severe (2%) harm. Handwritten rather than computerized discharges (adjusted odds ratio (adjusted OR) 1.60, 95% CI 1.11, 2.99), increasing number of medications (adjusted OR 1.26, 95% CI 1.21, 1.31) or chronic illness (adjusted OR 2.08, 95% CI 1.33, 3.24) were associated with non-reconciliation. Omission of endocrine, central nervous system and nutrition and blood drugs was more likely on discharge, whilst omission on admission and throughout inpatient care, without documentation, was more likely for obstetric, gynaecology and urinary tract (OGU) or respiratory drugs. Documentation in the discharge communication that medication was intentionally stopped during inpatient care was less likely for cardiovascular, musculoskeletal and OGU drugs. Errors involving the dose were most likely for respiratory drugs. Conclusions: The findings inform strategies to facilitate medication reconciliation on discharge from acute hospital care. 2011 The Authors. British Journal of Clinical Pharmacology 2011 The British Pharmacological Society.

Full Text: Available in fulltext at EBSCOhost  Available in fulltext at National Library of Medicine


Title: Medicines management.

Citation: Nursing Standard, Apr 2011, vol. 25, no. 33, p. 28., 0029-6570 (April 20, 2011) Author(s): Griffiths, M

Abstract: Advice on safety procedures which need to be followed when discharging patients with their prescribed medicines. The use of a self administration of medicines programme, and patient specific directions (PGDs) are discussed. [(BNI unique abstract)] 0 references

Full Text: Available in fulltext at EBSCOhost  Available in fulltext at ProQuest


AU: Bergkvist A AU: Midlöv P AU: Höglund P AU: Larsson L AU: Bondesson A

AU: Eriksson T

TI: Improved quality in the hospital discharge summary reduces medication errors--LIMM: Landskrona Integrated Medicines Management.

SO: European journal of clinical pharmacology YR: 2009 VL: 65 NO: 10 PG: 1037-46


AB: PURPOSE: We have developed a model for integrated medicines management, including tools and activities for medication reconciliation and medication review. In this study, we focus on improving the quality of the discharge summary including the medication report to reduce medication errors in the transition from hospital to primary and community care.METHODS: This study is a longitudinal study with an intervention group and a control group. The intervention group comprised 52 patients, who were included from 1 March 2006 until 31 December 2006, with a break during summer. Inclusion in the control group was performed in the same wards during the period 1 September 2005 until 20 December 2005, and 63 patients were included in the control group. In order to improve the quality of the medication report, clinical pharmacists reviewed and gave feedback to the physician on the discharge summary before patient discharge, using a structured checklist. Medication errors were then identified by comparing the medication list in the discharge summary with the first medication list used in the community health care after the patient had returned home.RESULTS: By improving the quality of the discharge summary, patients had on average 45% fewer medication errors per patient (P = 0.012). The proportion of patients without medication errors was 63.5% in the control group and 73.1% in the intervention group. However, this increase was not significant (P = 0.319). Patients who used a specific medication dispensing system (ApoDos) had a 5.9-fold higher risk of suffering from medication errors than those without this medication dispensing system (P < 0.001).CONCLUSION: Review and feedback on errors in the discharge summary, including the medication report and a correct medication list, reduced medication errors during the transfer of information from hospital to primary and community care.



AU: Al-Rashed SA AU: Wright DJ AU: Roebuck N AU: Sunter W AU: Chrystyn H

TI: The value of inpatient pharmaceutical counselling to elderly patients prior to discharge.

SO: British journal of clinical pharmacology YR: 2002 VL: 54 NO: 6 PG: 657-64


AB: AIMS: The use of medication and information discharge summaries (MIDS) has become a standard procedure in many hospitals. We have evaluated if these summaries, together with in-patient pharmaceutical counselling backed up with a simple medicine reminder card, may help with the delivery of seamless pharmaceutical care. METHODS: Elderly patients prescribed more than four items discharged to their own home received the standard discharge policy including a recently introduced MIDS and medicine reminder card. Each patient's GP was sent a copy on discharge. Pre-discharge a pharmacist counselled study patients about their medicines and compliance. A research pharmacist visited patients in their home approximately 2-3 weeks and at 3 months post-discharge to determine their drug knowledge, compliance, home medicine stocks and any healthcare related events. RESULTS: Forty-three study and 40 control patients completed both visits. Their mean (s.d.) ages were 80.2 (5,7) and 81.1 (5,8) years and they were prescribed 7.1 (1.8) and 7.1 (2.3) items, respectively. At visit 1 knowledge (P < 0.01) and compliance (P < 0.001) was better in the study group. At visit 2 compliance had improved in the study group (P < 0.001). Unplanned visits to the GP and readmission to hospital amongst the study group were 19 and 5, respectively, which were both significantly less (P < 0.05) than 27 and 13 in the control group. At visit 2 for the study group the 24 unplanned GP visits and three re-admissions were significantly (P < 0.05) less than the respective 32 and 15 in the control group. At visit 1, two study group patients had altered their own medication compared with 10 control patients. At visit 2 these reduced to 0 and 4, respectively. CONCLUSIONS: In-patient pharmaceutical counselling, linked to a medication and information discharge summary and a medicine reminder card, contributed to better drug knowledge and compliance together with reduced unplanned visits to the doctor and re-admissions. A pharmaceutical domiciliary visit consolidated the improved healthcare outcomes.