Medicines reconciliation discharge pathway

What is a simple discharge?

A discharge to home with no complex needs or planning required (~80% of patients).

What defines a complex discharge?

Patients needing ongoing health and/or social care or community services (~20% of patients).

Name three possible discharge destinations other than the patient's home.

Care home, another NHS hospital, prison.

What is intermediate care?

Time-limited support between hospital and home to aid recovery and prevent readmission.

Name two types of intermediate care.

Reablement and crisis response.

What is "bed blocking"?

When a patient is ready for discharge but remains in hospital due to delays.

What is the most common reason for NHS-related delayed discharges?

Awaiting further non-acute NHS care.

What % of delays were due to social care (as of June 2019)?

28%.

Name three common medication issues on transfer within hospital.

Omitted meds, wrong dose, route not available.

What can cause prescribing errors on discharge?

Incomplete discharge prescriptions, duplicate meds, poor documentation.

What can contribute to administration errors during patient transfers?

MAR charts not following the patient, delays in prescribing, wrong form.

What is the foundation for safe discharge prescribing?

Medicines reconciliation on admission.

Name three pharmacist roles in safe discharge.

Counselling, writing prescriptions, timely meds supply.

How can pharmacists prevent duplicate medications on discharge?

Reviewing PODs and the inpatient chart.

What does NICE NG5 recommend regarding reconciliation in primary care?

Should be completed within 1 week of GP receiving discharge info.

When should hospitals send discharge info to community pharmacies?

As soon as possible, if feasible.

What principle underpins person-centred care?

"No decision about me without me."

What does Standard 1.2 emphasise?

Supporting patients to understand medicines, benefits, risks, and alternatives.

What must be included in a discharge summary?

Full med list, reasons for changes, allergies, last dose date for relevant drugs.

Why is a discharge summary important?

Ensures continuity of care and accurate GP records.

What are typical shortcomings of discharge summaries?

Inaccuracy, incomplete content, and poor timeliness.

What is the NHS Discharge Medicines Service (DMS)?

A commissioned service aiming to reduce medicine-related harm after discharge.

What is TCAM?

Transfer of Care Around Medicines - an electronic referral system to community pharmacy.

What types of patients are flagged as high risk in DMS/TCAM?

Those on ≥5 meds, with recent medicine changes, or needing adherence support.

Name five high-risk medicines post-discharge.

Anticoagulants, insulin, methotrexate, lithium, opioids.

Why are newly initiated respiratory drugs considered high-risk?

Require dose titration and patient technique education.

What key info must be included in a DMS referral?

Patient demographics, medicine list, changes made, hospital code, referrer contact details.

What is the purpose of DMS and TCAM?

To optimise medicine use, reduce errors, and support patient understanding post-discharge.