Keeping patients safe when they transfer between care providers

Examples and recommendations of how you can implement some aspects from our Getting the medicines right report.


Communication between all health and social care professionals is vital to making this successful. In some cases this will require a significant shift in culture. Within the pharmacy some key communication links include:

  • Better communication and engagement between hospital and community pharmacy providers could be facilitated by those pharmacists working at a strategic health authority level. This will help to build relationships to help patient care as new services are developed
  • Community pharmacists could provide information to their secondary care colleagues if their patients are admitted into hospital
  • If pharmacists find inaccuracies with a patient’s medicines following a transfer of care, the patient’s GP should be contacted so that the inaccuracies are not continued. This could also be reported as a near miss or an intervention
  • Pharmacists working in all sectors should check unusual doses of prescribed medicines. In secondary care doses are often prescribed as a total dose rather than as unit doses so instead of two X 10mg tablets a dose of 20mg would be prescribed. If left unchecked it could lead to the supply of an unlicensed special.

This agenda should be integrated within the newly developing networks and structures within the reforming NHS in England, such as the clinical senates and other multi-professional networks.

Action: A Local Practice Forum (LPF) could take on the issue of post discharge MURs and start to discuss how this could be implemented at a local level to ensure patients who are discharged are identified to their community pharmacy and that the correct medicines information is transferred.

Opportunities for pharmacists to get involved

Pharmacists working in all sectors of pharmacy are the experts in the safe use of medicines  and can provide the input and support necessary to ensure medicines information is transferred accurately as patients move across care providers.

National guidance promotes the use of pharmacists working in secondary care to be involved in medicines reconciliation when patients are admitted into hospital.

If medicines are accurately recorded on admission then this enables a more accurate discharge for patients. Many hospital pharmacists are already involved in the discharge process and have a role in explaining new or changed medicine regimens to patients.

PRACTICE EXAMPLE: East Lancashire Hospitals Trust systems were reviewed to improve the quality of the medicines information contained in discharge summaries. Improvement measures include,  electronic patient tracking to identify patients requiring medicines reconciliation, re-design of Trust stationery, and training and electronic discharge summaries requiring a pharmacy check before they can be released. This means that the medicines information in the summary is provided to an accepted quality, as agreed with commissioners as part of the hospitals Quality Account.
Contact: Alistair Gray

PRACTICE EXAMPLE: At North Bristol NHS Trust the pharmacy recognised that, even though all dispensed medicines included an appropriate patient information leaflet, patients did not feel they had sufficient information about their medicines. This was shown within the CQC in-patient survey results. The department has operated a medicines help line for many years - which had very low usage. To publicise this, a small information card is included in all discharge prescriptions. Medicines management technicians and pharmacists also hand out these cards to patients on complex regimes or when patients may need to request further information. This simple intervention improved the organisations outcome on this measure by 5%.
Contact: Andrew Davies

Some hospitals have implemented systems that enable the medicines discharge information to be communicated to the patient’s community pharmacy to establish a co-ordinated approach across the system.

PRACTICE EXAMPLE: NHS Plymouth has, with Plymouth Hospitals NHS Trust, established arrangements for a high quality electronic discharge document including detailed information about medicines; a summary of the medication-related information is also produced for the community pharmacist. Having agreed what should routinely appear in discharge information, audit was subsequently used to drive continuous improvement.

Contact: Oksana Riley

Community pharmacists see patients on a regular basis but are may not be aware when they have transferred care settings. The new contractual arrangements due to be launched on 1 October 2011 in England, provide an opportunity for community pharmacists to carry out a post-discharge medicines use review (MUR). More information on the contractual changes is available from NHS Employers and PSNC.

Community pharmacists can already undertake an MUR on eligible patients after discharge, under the current MUR provisions. The professional guidance (link to it) describes the recommended core information that healthcare professionals should have access to when a patient arrives in their care setting and it is the responsibility of the healthcare professional transferring the patient to ensure that the core information is communicated when the patient moves between care providers. Community pharmacists could use the MUR as an opportunity to complete a ‘current medicines list’ with the patient so that they have an up to date record of their medicines.

If patients are prescribed a new medicine following a transfer of care then this could provide a prompt for the community pharmacist to initiate the New Medicines Service (NMS). For more information on the NMS please refer to NHS Employers or PSNC.

Primary care pharmacists have a pivotal role in supporting and facilitating implementation of the core roles and responsibilities. They can help to establish systems and processes to assist in the transfer of the core data set. Pharmacists working in commissioning organisations can work with provider colleagues to develop incentive schemes, for example through CQUIN or QIPP that can drive culture change. This agenda is a good fit with the QIPP programme since ensuring effective transfer of information potentially avoids waste, promotes adherence and prevents readmissions.

Pharmacists working within GP practices could take responsibility for ensuring that patients who have transferred across care settings have had their information accurately transferred and received.

PRACTICE EXAMPLE: The Old School Surgery in Bristol has a full time clinical pharmacist who critically reviews all discharge summaries after they have been scanned onto the medical records. She updates the patient's medication records and liaises with secondary care if any queries arise. Complex and high risk patients are highlighted to the doctors or the district nursing team for a post discharge review. She also works closely with community pharmacists especially for those patients receiving monitored dosage systems."
Contact: Rachel Hall

Patient safety incidents

All healthcare professionals are encouraged to report incidents that could or do cause severe harm to the National Reporting and Learning System (NRLS). The new contractual requirements for community pharmacists due to be implemented in October 2011 strengthen this requirement. This includes not only errors made by pharmacists but also those made by colleagues outside of the pharmacy, for example by the prescriber.

If you would like more information please contact Heidi Wright

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