Hospital Prescribing - Getting discharge summaries right

Consortia need to insist that hospitals supply accurate drugs data.

Non-existent or misleading hospital discharge summaries can lead to medication errors and legal claims from affected patients (Photograph: SPL)
Non-existent or misleading hospital discharge summaries can lead to medication errors and legal claims from affected patients (Photograph: SPL)

Hopefully, one excellent and overdue outcome of giving commissioning powers to GPs will be that we conquer the problem of inadequate or no hospital discharge summaries about our patients and their medication.

However, getting the discharge process and summaries right is not a simple matter.

We all know patients whose medications were changed, stopped or replaced without explanation to their GP, the practice, the patient or the carer. Not surprisingly, medication errors occur and are a common reason for legal claims.

Prescribing safety
There are good reasons why hospital admission, with an acute episode of existing illness or a new diagnosis, may result in the drugs the patient was taking on admission being stopped and new drugs given. But when GPs are asked to continue prescribing a treatment initiated in hospital, we should have enough information to prescribe the drug safely.

If the discharge slip does not contain enough information about the changes that have occurred, the result can be treatment failures, continuation of inappropriate medication and discontinuation of required medication.

Good prescribing is one of the criteria of the GMC's Good Medical Practice guidance.

GPs are responsible if a patient suffers drug-related harm by inadvertently following a consultant's instructions.

We are also responsible if we do not spot hospital-initiated medications - for example, if a practice receptionist prints all the items on the discharge medication slip and the GP simply signs the prescription without noticing the changes.

From April 2013, GP consortia will commission the majority of NHS services for patients, and meaningful control of limited resources will mean looking at three Es - efficiency, effectiveness and economy - to ensure outcomes are optimised for the level of funding used.

With these provisos in mind, our practice at the Chadderton South Health Centre in Oldham, together with another Oldham practice, last year undertook an audit of medications prescribed on discharge to ensure consistency and effectiveness and to reduce medication errors. As well as harming patients, the last can result in costly re-admissions. See the box below for how we carried out the audit and the results.

Results show a problem
Our audit was presented to the local medicine management committee in January 2011 as part of its Quality, Innovation, Productivity and Prevention (QIPP) agenda to prevent ill health and re-admission.

The results indicated a problem, but we could not say how many resulted in re-admission. The difficulty in interpreting the results comes from the reasons why what should have happened did not.

For example, it is justifiable not to give a seven-day supply if the patient already has a large amount of the medication, but how is the GP supposed to know that if it is not documented? If the consultant's name is missing, who should the GP contact if there is a concern about the medication?

A delay in getting summaries means the practice does not know what happened when the patient was in the hospital. It is not appropriate to rely on the patient/carer to provide details about the drugs they have been asked to take and why.

Our audit's limitations included small sample size. Only one hospital site's discharge summaries were studied and surgical cases were not included. Nevertheless the medicine management committee acknowledged there are problems in communicating discharge medications information.

We intend to continue the audit, involve more practices and extend it to other practices to get a wider picture. The solution is collaborative working by health professionals to identify how to improve the discharge process. This type of research will help GP consortia when they take on real budgets and face real, fiscal consequences for overspends.

Once GP commissioning is fully in place, consortia will have more control over acting in the best interests of patients.

Including pharmacists in practice teams would be a good safeguard for patients and, may be, there is a need for electronic discharge prescriptions.

DISCHARGE MEDICATIONS AUDIT

AIMS

  • To evaluate the quality of information given on hospital discharge prescriptions.
  • To develop a system to reduce medication errors.
  • To investigate additional expenditure as a result of medication errors.

METHOD

  • Discharge data was collected from two Oldham practices from June to November 2010 by a fourth year University of Manchester medical student attached to Dr Sharma's practice.
  • Only medical discharges were included in the audit.
  • A computer search of all medical admissions, irrespective of duration of stay, was undertaken and details of medication taken at the time of admission were recorded.
  • Admission and discharge medications were reconciled and significant changes (drugs stopped or added, major dosage changes) were noted.
  • Noted changes were evaluated for quality of information given to the GP using a pro forma document.
  • The data was collated on a computer spreadsheet.
  • The potential clinical significance of any discrepancy in discharge medication was assessed.

RESULTS

  • Discharge summaries were received in 58 per cent of cases.
  • Only 6 per cent arrived within 48 hours.
  • Nineteen per cent of summaries stated that the patient had received seven days' supply of their medication.
  • Regular medication was documented in 30 per cent.
  • Regular medication was stopped for 59 per cent of patients during their hospital stay with no reason stated and, at discharge, 39 per cent were prescribed new drugs, again with no reason stated.
  • The consultant's name was identifiable in only 42 per cent of cases.
  • Allergies were not documented in 26 per cent of cases.
  • The discharge date was missing for 35 per cent.
  • The diagnosis was omitted from 35 per cent.
  • Dr Sharma is a Greater Manchester GP and Lyndsey Black is a fourth year medical student at Manchester University.

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