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Reducing prescribing discrepancies following hospital discharge: the UK perspective

Published: 6 October 2006

Corresponding Author: Catherine Duggan, Director of the Academic Department of Pharmacy, Barts and the London NHS Trust, and Senior Clinical Lecturer, Department of Practice and Policy, School of Pharmacy, University of London




catherine dugganFor more than a decade it’s been known that patients moving between hospital and community are at risk of unintended changes to supplies of medicines. These risks increase with age and the corresponding increases in prescribed drugs. Indeed, as early as 1986, inconsistencies in prescribing were identified for drugs prescribed for psycho-geriatric patients. These were often a result of poor communication [1], and it was recommended that information should be passed from GPs to consultants when patients were admitted to hospital to reduce such problems [2].

Research published in the early 1990s found changes in the supplies of drugs for 45 of 50 elderly patients, often due to a lack of communication between the healthcare sectors [3]. At that time, such studies concentrated on older people, who tend to be prescribed more drugs and move in and out of hospital more than general medical patients.



How big is the problem?

We sought to assess whether discrepancies in prescription occurred in the drug supplies of general medical patients, to identify where they occurred, and to test an intervention to reduce their incidence.

We recorded the supplies of prescribed drugs obtained by general medical patients as they returned home after a hospital stay. Unintentional discrepancies were observed in 47% (77/164) of the supplies of prescribed drugs obtained in the community following discharge [4]. Our solution to these problems was to communicate information regarding drugs prescribed at discharge to the community pharmacist.



Our study

We recruited 501 patients to the intervention study: 264 in the intervention group (provided with information regarding drugs prescribed at discharge to give to their community pharmacist) and 237 in the comparison group (provided with no such information).

We found a significant reduction of discrepancies considered to have a definite adverse effect on the patient in the intervention group. Such discrepancies were observed in 1.6% (23/1408) of supplies of drugs in the intervention group compared with 3.1% (41/1328) of drugs in the comparison group [5]. The relative risk of experiencing such a discrepancy was reduced by 37% as a result of the intervention for minimal additional cost (less than an additional £3).

For every 19 patients discharged from hospital with a copy of the drugs prescribed at discharge to take to their community pharmacist, an unintentional discrepancy with an adverse outcome was prevented.

Advantages of transfer of information to the community pharmacist

  • The information is simple and cost effective to produce and will augment any discharge process already in place.
  • The information could be sent electronically to ensure that it’s readable, comprehensive and arrives at the community pharmacy in a timely fashion.
  • Our study showed that community pharmacists can resolve any drug related problems with their general practitioner colleagues.


Effect of the intervention on hospital readmission

Further research by our team has gone on to identify the potential risks for a readmission to hospital as a direct result of drug related problems.
The work involved testing our standardised documentation of drug related information to assess whether it would help identify drug related problems as well as the suitability for transfer across the healthcare interface. The effect of this drug related information transfer was tested on defined patient outcomes:

  • readmissions to hospital
  • utilisation of primary care services
  • drug related problems.

A multi-method approach was undertaken to inform the study design and to ensure involvement and ownership by the participating practitioners. In a randomised controlled trial, the trial group consisted of general medical patients who received a pharmaceutical care plan at discharge to deliver to their GP and community pharmacist [6]. Patients in the control group received the usual discharge care. All patients were followed up at 30 and 60 days after discharge to establish the number of:

  • GP/practice nurse and community pharmacy visits
  • readmissions to hospital
  • patient reported drug related problems after discharge.

We found that patients taking more medicines were at greater risk of changes, and the commonest drug related problems were among patients with a cardiac or respiratory diagnosis—not surprisingly the majority of general medical patients.

Patients reporting a drug related problem were more likely to visit their GP or community pharmacist following discharge. Those with four or more admissions in the previous 12 months were more likely to have a respiratory diagnosis; to be prescribed more medicines at discharge (median of 8); and less likely to have had a medicine initiated during their hospital stay.

We found an increased time to readmission in the trial group. The paper based communication was able to delay readmission by communicating any problems for resolutions after discharge. But readmission wasn't prevented—probably due to the high level of morbidity in this patient group. This is an important finding, especially in this population in which 20% were readmitted within the study period (60 days).

We subsequently developed a risk profile for such patients to identify other contributors to their readmission (Box 1).

Box 1 Risk factors for readmission to hospital

  • Number of previous admissions
  • Number of prescribed drugs
  • Number of changes to drugs
  • The patient's age









What we learnt: the importance of standardised documentation

The studies detailed here suggest that:

  1. All patients should be discharged with standard information for their community pharmacist, 2. All patients should then be stratified by their risk factors so that they can be targeted for appropriate add-on care and referred to the appropriate professionals.

This standardised documentation provides a method of noting the pharmacist’s contribution to patient care. Currently this isn’t routinely undertaken, but it’s vital for demonstrating effective medicines management across the healthcare interface.



Learning points

  • When patients are discharged, there’s a risk of unintended changes to their medication, not only in older but also in younger general medical patients.
  • Patients taking more medicines are more at risk of changes, and drug related problems are commonest among patients with a cardiac or respiratory diagnosis
  • Such changes and problems can result in readmission to hospital in up to 20% of this population.
  • With standardised documentation on drugs prescribed at discharge for community pharmacists, the time to readmission can be delayed or prevented.



  1. Linter CM. A study of prescribing for day hospitals. The Practitioner 1986;230:16-20.
  2. Short D. Informing the hospital of patients' drug regimens. BMJ 1986;292:412. [Free PDF].  bmj journals logo
  3. Cochrane R, Mandal A, Ledger-Scott M, Walker R. Changes in drug treatment after discharge from hospital in geriatric patients. BMJ 1992;305:694–6. [Free PDF] bmj journals logo
  4. Duggan C, Bates I, Hough J. Discrepancies in prescribing—where do they occur?  Pharmaceutical Journal 1996;256:65–7.
  5. Duggan C, Feldman R, Hough J, Bates I. Reducing adverse prescribing discrepancies following hospital discharge. International Journal of Pharmacy Practice 1998;6:77–82.
  6. Bateson C, Duggan C, Bates I. Evidence-based practice: barriers to undertaking research in practice. Ninth Health Services Research and Pharmacy Practice Conference, Queen’s University, Belfast 2003. London: Royal Pharmaceutical Society, 2003:28.



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