NPC Archive Item: Managing patients’ medicines after discharge from hospital – a National Study from the Care Quality Commission

NOTE – This is an archive post from the NPC and has not been updated since first publication. Therefore, some hyperlinks may no longer be working.

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7 December 2009

In October 2009 the Care Quality Commission (CQC) published a report of a national study carried out on ‘Managing patients’ medicines after discharge from hospital’1 to look at what organisations were doing to ensure the safety of patients who had been discharged from hospital with a change of medication.

The CQC visited 12 primary care trusts (PCTs) across England, as commissioners of primary and hospital care, and surveyed 280 of their GP practices. During its visits, the CQC saw some evidence of good practice, including good systems to ensure safe repeat prescribing, and medication reviews for high-risk patients following hospital discharge, but also identified the following concerns:

  • Information shared between GPs and hospitals when a patient moves between services is often patchy, incomplete and not shared quickly enough
  • Updating of GP patient records is not always carried out by clinical staff and left to administrative staff instead
  • GPs do not routinely review new medication with a patient following discharge making it more difficult for patients to manage their medicines appropriately
  • GPs are not consistently reporting medication incidents and PCTs are not always monitoring them, increasing the likelihood of these incidents occurring again.1

The report makes a number of recommendations to organisations and health professionals involved in providing, commissioning, regulating, and setting standards for care. These recommendations are summarised below:

PCTs should:
Work with GPs to agree the use of standard referral forms covering elective and emergency admissions. (The report recommends taking into account guidance from the NPC)2; Clarify expectations of GP practices in relation to reconciliation, medication review, and repeat prescribing; Make far better use of information they have on GP medicines management performance; Ensure that contracts with acute trusts cover timeliness and content of discharge summaries (these must include diagnosis and reasons for changes to medication); Improve systems that monitor acute trust contractual obligations regarding discharge summaries and letters; Evaluate the level of pharmacist support available, and how it is being used; Ensure information is shared effectively; Ensure that those involved in the exchange of information follow the NHS code of confidentiality.

GPs should:
Ensure they carry out a higher proportion of medication reviews with the patient present (this would be consistent with a type 2 and type 3 medication review, as referred to in ‘A Guide to Medication Review 2008’3); Share their learning by recording instances when the medicines pathways go wrong, and reporting them appropriately.

Community pharmacies should:
Report instances of prescribing error to PCTs so that lessons are learned and patient care is improved; ensure that the categories of patients identified by their local PCTs are offered a Medicines Use Review (MUR).

Acute trusts should:
Ensure that their clinicians are aware of their obligations re: admission and discharge summaries; Provide feedback to PCTs when information from GPs is late or incomplete; Review medicines management arrangements in readiness for the introduction of registration with the CQC (April 2010).4

In addition, CQC has asked national bodies including the Department of Health, NHS Connecting for Health, and NHS Employers and the General Practitioners Committee to review the aspects of electronic communication arrangements, Pharmaceutical Services Directions, and QOF target and indicators that they are responsible for, with a view to supporting improved management of patient information following discharge from hospital.

PCT commissioners and medicines management teams are able to assess their own performance in medicines management following discharge by using a self-assessment tool produced by the CQC.

Studies suggest that almost half of all patients may experience an error with their medication after they have been discharged from hospital, and 19-23% of patients suffer an adverse event, most commonly an adverse drug event.5

In addition, analysis of the total number of incidents in England reported to the NPSA’s National Reporting and Learning Service (NRLS) between April 2008 and March 2009, identified medication as being the most common incident type reported in general practice (24%), followed by information sharing incidents – consent/communication/confidentiality (12%) and documentation (12%).6 In contrast, acute/general hospitals reported medication errors as the third highest incident type (10%), with problems with documentation responsible for 7% of reports and consent/communication/confidentiality issues 4%.6

The need for improving communication about patients medicines, following a transfer of care from one setting to another, was highlighted by the NPSA and NICE in their patient safety solution guidance of December 2007.  This was soon followed by the NPC Guide to Implementation in February 2008.

The release of this timely report from the CQC highlights again that work that still needs to be done to improve communication about patients’ medicines at care transition points.

What does this mean to medicines management?
PCTs, commissioners, GPs, community pharmacists, and clinicians in acute trusts should continue to work together to improve the sharing of information for the safety of their patients and to ensure that NHS resources are used more efficiently and effectively. Improved communication between the hospital and GP could help to prevent any breakdown in contractual agreements.

Patient care across all interfaces needs improved systems in place so that on each occassion a patient moves between care settings their medical notes are accurate, complete and presented in a timely manner, so that the patient and care provider are confident that the records include “a complete list of medicines, accurately communicated”.7

The root of the problem from a medicines management point of view is a breakdown in communication, which can occur due to differences in the way teams work, the availability of resources, different information services and different organisational priorities.8 Barriers to medicines reconciliation will generally be related to one or more of the following issues: systems, skills, people, organisations and resources.2 Healthcare professionals should work together to overcome barriers, improve communication, and reduce the risks that are associated with these issues.

How does this relate to other publications or evidence?
The NPC has produced guidance on medicines reconciliation, which includes a minimum dataset of information for primary and secondary care that can be amended according to need. Additionally, the NPC and NPC Plus document ‘A Guide to Medication Review 2008’ has shared examples of how medication review has been implemented, and promotes mechanisms for monitoring the impact of medication review on the health of local populations and individuals.

Further tools and resources for those wanting to find out more information are available on the NPC floors: Reducing medication errors, Introduction to medication review, Medicines reconciliation, and Medicines Use Reviews.

1. Care Quality Commission (2009). Managing patients’ medicines after discharge from hospital.

2. NPC (2008). Medicines Reconciliation: A Guide to Implementation.

3. NPC (2008). A Guide to Medication Review 2008.

4. Care Quality Commission website. New registration system. Available at: [Accessed 18th November 2009].

5. Kripalani S, Jackson, AT, Schnipper JL, and Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists, Journal of Hospital Medicines, 2007, Vol2, No 5, 314-323.

6. National Patient Safety Agency. Patient safety incidents reports in the NHS: National Reporting and Learning System Quarterly Data Summary. Issue 13: August 2009 – England.

7. Institute for Healthcare Improvement,

8. NPC (2008). Moving towards personalising medicines management: Improving outcomes for people through the safe and effective use of medicines.

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