Discharge Letters

Medication reconciliation is essential for patient safety at the transition between secondary and primary care. The CQC found that 17% of GP practices rely on non-clinical staff to update patient records post-discharge, creating significant risk. Around 4% of all hospital admissions are due to preventable medicine-related issues, with this figure rising to 40% for errors occurring during handoffs between healthcare providers. Our service ensures qualified clinical pharmacists handle this critical process, preventing medication errors that can lead to serious harm, readmissions, and emergency department visits.

Our team takes care of the whole process from coding and medication changes to post-discharge reviews. When discharge letters arrive, our clinical pharmacists review them promptly, compare the patient's current medications to those taken before admission, identify discrepancies, update prescriptions accordingly, and contact patients to discuss changes. We also communicate with community pharmacies to ensure they're aware of medication changes and work with your in-house pharmacy team to implement any monitored dosage systems for vulnerable patients, ensuring continuity of care.

Processing discharge letters can consume 10-20% of a GP's typical working day, according to current data. By delegating this workload to our trained Clinical Pharmacists, practices typically free up approximately 4 hours of GP clinic time per day. This allows GPs to shift their focus to more complex patients, strengthening the doctor-patient relationship while minimising the risk of errors and maximising the potential for continual patient care and safety. The time savings are particularly significant given the increasing volume and complexity of discharge information from secondary care.

Patient safety is our primary concern. Our clinical pharmacists have the critical thinking skills and training to spot potential medical interactions and risks. We follow a structured approach to medication reconciliation that includes: thoroughly reviewing the discharge summary, comparing it to pre-admission medications, identifying any changes, updating prescriptions accordingly, and checking for potential drug-drug interactions. We also contact patients directly to explain medication changes, verify their understanding, and address any concerns. For elderly and chronically ill patients on complex medication regimens, we provide additional monitoring and support.

Yes, our service fully aligns with NHS England's Discharge Medicines Service (DMS) requirements. The DMS is designed to ensure better communication of changes to a patient's medication when they leave hospital, reducing the risk of avoidable harm. Our service implements the recommended three-stage process involving primary care, the hospital, and community pharmacy. We've incorporated all subsequent changes advised by CQC and NHS England into our service model, helping minimise the risk of patient harm post-discharge and supporting the national initiative to reduce medication errors and readmissions.