Medicines Reconciliation After Hospital Discharges

Accurate medicines reconciliation after hospital discharge prevents avoidable harm and shows patients that primary care and secondary care are working together. A structured approach keeps responsibilities clear and ensures follow up happens on time.

Follow a 48 hour framework

1. Day 0: Receive the discharge summary, log it, and allocate the case to a named pharmacist or clinician.
2. Day 1: Compare discharge medicines with the GP record, identify discrepancies, and confirm monitoring requirements for high risk drugs.
3. Day 2: Update repeats, issue interim prescriptions if needed, document clinical decisions, and arrange follow up contact or appointments.

Clarify team roles

• Clinical pharmacist: Leads the review, liaises with hospital pharmacy, and documents rationale for each change.
• Care coordinator or admin lead: Books follow up calls, contacts community services, and updates shared care records where available.
• GP or nurse prescriber: Reviews high risk decisions, authorises changes, and ensures safety netting advice reaches the patient.

Communicate clearly with patients and partners

• Use structured call scripts or letters covering new medicines, stopped medicines, side effects, and follow up tests.
• Notify community pharmacy, care homes, or carers when changes affect their responsibilities.
• Record consent, advice given, and any patient questions in the clinical system.

Measure quality and improvement

• Track completion rates within 48 hours for priority groups such as frail patients, those on multiple medicines, or recent readmissions.
• Audit resolved discrepancies and incidents avoided to demonstrate impact.
• Collect patient feedback on clarity of information and confidence in managing their medicines.

Sustain the workflow

• Hold a short multidisciplinary review each month to discuss recurring issues and agree improvements.
• Refresh staff training when hospital templates or electronic discharge pathways change.
• Log resource constraints or repeated issues to support commissioning discussions or requests for additional clinical pharmacy time.

Take the next step

Apply the 48 hour workflow to the next batch of discharge summaries and share the findings with the multidisciplinary meeting. Use evidence from the pilot to explore premium templates, dashboards, and patient communication packs that help scale the process across the practice or PCN.

Disclaimer

This guidance is for general information. It is not a substitute for legal, clinical, or specialist advice. Always seek professional support tailored to your practice.