After hospital discharge: do the medicines match?
When someone returns from hospital, their medicines may not be the same as when they left.
A medicine may have been started, stopped or temporarily withheld. The dose, timing, route or formulation may have changed. A short course may have been prescribed, or the hospital may have supplied only enough medicine for the first few days.
The person may arrive with a discharge summary, a bag of medicines and an existing medicines administration record (MAR) that no longer agree with one another.
This is why a hospital discharge should trigger a prompt medicines reconciliation check.
What is medicines reconciliation?
Medicines reconciliation means producing an accurate list of the medicines a person is currently intended to take, comparing it with the information and medicines available, identifying discrepancies and documenting any changes.
The Care Quality Commission advises that this should be completed as soon as possible when someone has been discharged from hospital or another care setting. It should be carried out by trained and competent staff, with appropriate input from a GP, nurse, pharmacist or other relevant health professional.
The aim is not simply to copy the discharge list onto the MAR. It is to establish what the current instructions actually are and make sure that everyone involved in the person’s care has the same accurate information.
- Gather the available information
Check the discharge summary, medicines supplied, current MAR, care plan and any additional written instructions.
Where appropriate, involve the person and their family or carer. They may be able to explain how medicines were taken before admission or highlight something that appears different.
Do not rely on a single source if other relevant information is available.
- Check every medicine—not only the obvious changes
For each medicine, compare:
- name and formulation
- strength and dose
- time and frequency
- route of administration
- indication or reason for use, where recorded
- whether it is regular, time-critical or required only when needed
Look specifically for medicines that have been started, stopped, replaced or temporarily withheld.
Remember to include inhalers, creams, patches, eye drops, injections, nutritional products and over-the-counter or complementary medicines where these form part of the person’s support.
- Check the supply
The medicines physically supplied should match the current instructions.
Check whether there is enough medicine to continue treatment until the next supply is available. Identify anything requiring refrigeration, secure storage or rapid access, such as insulin or rescue medicines.
Keep medicines that are no longer intended for use separate from the current supply and follow the organisation’s disposal policy. Do not continue using an old medicine simply because it remains available.
- Resolve discrepancies—do not guess
A discrepancy might include:
- a medicine listed but not supplied
- a supplied medicine missing from the discharge summary
- conflicting doses or administration times
- unclear instructions for a short course
- an existing MAR that still includes a stopped medicine
- missing information about allergies or previous reactions
Staff should follow the provider’s policy, pause where necessary and seek clarification from an appropriate health professional. The action required will depend on the medicine, the timing of the next dose and the level of clinical risk.
Time-critical medicines require particularly prompt escalation. A discrepancy should not be allowed to become an avoidable omission through delay.
- Update the records and handover
Once the correct instructions have been confirmed, update the relevant records in line with local policy and document:
- what discrepancy was identified
- who was contacted
- what advice or authorisation was received
- what changes were made
- who needs to know
Communicate the outcome to the staff responsible for the next medicine round or care visit. A corrected record is only effective if the people delivering care know that it has changed.
A useful final check
Before the next administration, ask:
Do the discharge information, medicines supplied, MAR and care plan now tell the same story?
If they do not, the medicines reconciliation process is not complete.
Safe Skills Training provides practical medicines-management and clinical training for care providers, helping staff recognise risk, work within their competence and respond safely when information does not agree.
Visit www.safeskillstraining.com to discuss training for your team.
FURTHER GUIDANCE
Care Quality Commission: Medicines reconciliation
https://www.cqc.org.uk/guidance-providers/adult-social-care/medicines-reconciliation-how-check-you-have-right-medicines
NICE NG5: Medicines optimisation
https://www.nice.org.uk/guidance/ng5/chapter/1-recommendations