Medicines reconciliation pilot at transfer of care: admission to a community-based early supported discharge (‘step-down’) and prevention of admission (‘step-up’) service

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Early supported discharge (‘step-down’) and prevention of admission (‘step-up’) services require safe medicines reconciliation. Medication discrepancies at transfer of care are a potential cause of patient harm. There is currently no published work examining level of medication discrepancies and associated risk in this setting.


Working within a ‘step-up’ and ‘step-down’ integrated service based in the community, caring for patients in their home to:


▸ quantify the number of medicines discrepancies and allergy status discrepancies


▸ ascertain the type of discrepancies


▸ assess the potential for harm caused by these discrepancies.


Medicines reconciliation was performed by two pharmacists for patients within the ‘step-up’ and ‘step-down’ service as well as patients recently discharged from hospital to a care home. The resulting medication history was compared with the original medication history documented in the service's notes. Allergy status and medication discrepancies were identified and the type of discrepancy was recorded. National Patient Safety Agency (NPSA) risk assessment was used to categorise the level of risk of each discrepancy.


20 out of the 54 patients (37%) did not have an allergy status recorded at baseline. Of the 573 medications listed for patients reviewed following medicines reconciliation, 317 (55%) had a medication discrepancy. There was an average of 5.87 (95% CI 4.53 to 7.18) medication discrepancies per patient of which 49% were classified (NPSA) as moderate, high or extreme risk.


There was a high level of medication discrepancies in this service with implications for patient safety and cost. Such services would benefit from pharmacist-led medicines reconciliation.

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