The challenge of discharge: combining medication reconciliation and discharge planning

The appropriateness, safety and timeliness of individualised medication plans must be improved

The article by Tong and colleagues in this issue of the Journal1 describes a trial in which pharmacist-completed medication management plans in electronic discharge summaries were compared with standard medication management plans completed by medical officers. The pharmacist-completed medication plans were found to include significantly fewer potential errors, including high and extreme risk errors, than standard medication plans. The authors noted some limitations to their study. We also acknowledge general limitations in this area, specifically that transcribing errors have not been clearly correlated with adverse events, although they have potential to be so. This is perhaps because some transcribing “errors” are appropriate and intentional omissions from the discharge scripts, but this is not well communicated. Some potential errors may be both high and low risk errors, depending on the drug, patient and the clinical situation, and therefore only cause adverse events in some situations, which may have been factored in by the discharging team. The transcribing errors counted in the study by Tong and colleagues include omitted drugs, whether appropriate or not, and errors with the potential to cause an adverse event.

Medication errors are currently topical, with a number of Australian regulatory, safety and quality committees, such as the Australian Commission on Safety and Quality in Health Care, examining methods to reduce their number.2 Australian studies have found that the number of prescribing errors ranges from two (in paper-based charts) to six errors (electronic prescribing records) per patient.3 However, determining which of these errors are clinically relevant, and which may only be significant in combination with other factors (such as dehydration or a falls risk), can be difficult to ascertain. It is also important to distinguish between types of errors, as some are more important than others; for instance, an incorrect choice of drug compared with incorrect use, incorrect concomitant medication, or misreading or spelling mistakes.

Medication errors are also topical because patients admitted to large teaching hospitals increasingly have a significant number of comorbidities, and are taking ten or more medications at discharge.4 Further, medication problems are a significant cause of both admission and re-admission.5

Medication error is of particular concern when there are transitions in care, such as discharge from hospital. In addition to the accuracy of the medication management plan, the timeliness, mode of delivery of information (electronic, phone or fax), and quality of content (including context) are key elements of clinical handover.6 Errors are also commonly made in medical diagnoses, as well medications, in information communicated to or from general practitioners.7

Where do we go from here? The study by Tong and colleagues highlights a possible weakness in the current model, in which medication reconciliation is delegated to a junior member of the team, together with the perception of the low implicit value of the task. For most hospitals, providing a 24-hour/7-day pharmacist service as described in this study (necessitated by the fact that not all patients are discharged during business hours) is unlikely to be feasible. In smaller hospitals and locations in rural and remote Australia, its practicality is even more problematic because of small patient numbers and limited hospital staff numbers. A pharmacist-only medication reconciliation model as recommended by the authors also runs the risk of isolating medication reconciliation from other aspects of the discharge plan.

Interestingly, a recent study identified differing and overlapping perceptions of nurses, doctors and pharmacists about their roles at the time of discharge, each perceiving that their disciplines have key roles.8 This overlap may need to be considered when designing the way forward. A recent study suggested that junior medical staff can be educated to increase the quality of medication information and reconciliation.9 The critical role of this activity should be highlighted to supervising medical staff to ensure that junior staff are supported by a multidisciplinary team, including a pharmacist, focused on patient outcomes, and by clinically facilitative IT and workflow systems that ensure audited and targeted accuracy of medication reconciliation. This approach would also improve the transfer of other care management information from the hospital setting. Accuracy and quality of a multifaceted discharge summary (as judged by receiving community doctors) could become an important quality indicator for hospital teams.

There are other ways doctors can generally improve the quality of the discharge summary, check the medication information for appropriateness and accuracy, and guarantee timely follow-up with community colleagues. These include ensuring that clinical pharmacology training (including prescribing) to an appropriate standard is included in medical programs,10 as well as learning teamwork skills to facilitate working together with pharmacists in drug and pharmaceutical matters. These competencies can be refreshed and reinforced during junior doctor training.11 A more senior doctor on the team checks the discharge letter prior to discharge in some medical teams; others insist that the doctor communicates directly with their GP colleague at discharge. Discussing changed medications with the pharmacist at discharge would also be useful.

In conclusion, medication and medical care reconciliation are key components of clinical handover. Reduced rates of transcription errors must be achieved, and the appropriateness, safety and timeliness of individualised medication plans improved. Better communication of the other, complementary components of discharge, such as the need for ongoing monitoring and management and of specialist follow-up, require vigilance to ensure that patients are best served during the transfer of their clinical information.