Official Journal of the Society of Hospital Pharmacists of Australia
Improving medicine information on discharge summaries through implementation of a reconciliation-based intervention Anna Nguyen, BPharm (Hons), GradCertPharmPrac, Stephanie Gibson, BPharm (Hons), MClinPharm , Paul Wembridge, BPharm (Hons), MClinPharm
Pharmacy Department, Eastern Health, Box Hill, Australia
The handover of medication-related information at the point of discharge often occurs via the discharge summary (DS), although these frequently contain errors. We aimed to investigate whether an intern pharmacist reviewing the medication details in discharge summaries (DSs), reconciling them with the discharge prescription and pointing out any discrepancies with the medical staff would reduce the rate of medication errors. The intervention was retrospectively reviewed by comparing medication information on the DS with the discharge prescription (considered the ‘source of truth’). Error rates on the DS were compared to a control group of patients discharged over a different 2-week period from the same ward. A modified APINCH (Antimicrobials, Potassium and other elec- trolytes, Insulin, Narcotics and other sedatives, Chemotherapeutic agents, Heparin and other anticoagulants, Systems) classification system was used to identify high-risk errors. The time taken to perform the intervention was measured and details of any recom- mendations collected. The study included 22 intervention patients and 31 control patients. Patients who received the intervention were less likely to have one or more medication errors on their DS (any: 4% vs 84%, p < 0.01; high-risk: 0% vs 29%, p < 0.01). The intern pharmacist made a total of 77 recommendations during the intervention. Six recommendations (8%) related to high-risk medi- cations. The median time required to undertake the first review was 4 min, and the second review took 1 min. In conclusion, we found a reconciliation-based intervention involving an intern pharmacist could reduce the rate of medication errors on DSs.
Keywords: safety, patient safety, quality assurance, discharge, hospital.
The generation and distribution of an accurate medication list to receiving clinicians at transitions of care is a requirement of the Australian National Safety and Qual- ity Health Service Standards.1 It is common practice for such a list to be included as part of medical discharge summaries (DSs); however, research has demonstrated that up to 80% of DSs have errors, with even higher rates in patients with polypharmacy (≥5 medications).2–7
Pharmacy-based interventions have demonstrated signifi- cant improvements in the accuracy of medication-related information in DSs, although these have been undertaken by registered pharmacists and therefore may not be an option in resource-constrained health services.4,5,7
Clinical pharmacy services are provided on a criterion- based referral system at our institution (Eastern Health).
Patients referred to pharmacy will receive clinical phar- macy services as described by the Society of Hospital Pharmacists of Australia, including reconciliation of medicines on discharge.8 At our institution, the DS is pre- pared by medical staff, and clinical pharmacists do not review or have input into this document. All medications continued on discharge must be included on discharge prescriptions.
At our institution, both discharge prescriptions and DSs are generated via a Cerner-based (Oracle Corpora- tion, Kansas City, Missouri, US), electronic medical record (EMR) system. The DS medication list is auto- populated by ‘active medications’ on the patient’s pro- file; this consists of medications prescribed on discharge and any pre-admission medications which are to con- tinue. Decision support tools are available to assist pre- scribers in reconciling medications on discharge, although internal auditing has identified that uptake remains poor (51% of multiday inpatient discharges in April 2022). Although ideally a DS should be prepared once the discharge medications have been finalised, the
*Address for correspondence: Paul Wembridge, Pharmacy Depart- ment, Eastern Health, 8 Arnold Street, Box Hill 3128, Victoria, Aus- tralia. E-mail: [email protected]
� 2022 Society of Hospital Pharmacists of Australia. Journal of Pharmacy Practice and Research (2022) 52, 454–457
doi: 10.1002/jppr.1828

complex and unpredictable nature of high-turnover areas and pressure to discharge patients at the earliest opportunity frequently results in DSs being commenced prior to finalisation of discharge medications.
The aim of this study was to test the hypothesis that once a clinical pharmacist has clarified the intended medications on discharge as part of the discharge recon- ciliation process, further checking to ensure consistency with the DS is a task which could be undertaken by staff with less training, such as intern pharmacists or technicians.
The intervention took place between 22 July 2020 and 31 July 2020 on a 32-bed general medicine ward at a metropolitan hospital. Discharge prescriptions were pre- pared by medical staff utilising the EMR and then reviewed and reconciled by a clinical pharmacist as per existing processes. Once the discharge prescription was deemed accurate by both the clinical pharmacist and the prescriber, a photocopy was provided to the intern pharmacist. A single intern pharmacist participated in the intervention, and all patients reviewed by a clinical pharmacist were included.
When medical staff completed a DS, the intern phar- macist would be notified in person, by phone or elec- tronic instant messaging, and subsequently compared the DS with the photocopied prescription. Discrepancies were summarised in writing and provided to the medi- cal staff, who revised the DS. The intern pharmacist then conducted a second review to ensure the discrep- ancies had been resolved. The time required to under- take the review and create a written summary of discrepancies was recorded for subsequent analysis. Time measurements were undertaken by the intern pharmacist participating in the intervention. Travel time was excluded from measurements.
The effect of the process on DS accuracy was assessed via retrospective medical record review of the final DS. A DS was considered accurate when the medications listed matched the discharge prescription, including medication name, formulation, dose, frequency and route and when there were no omissions or duplica- tions. This method has been used elsewhere in the assessment of DS medication errors.4,6 Any discrepan- cies between DS and prescription were considered errors. Data collection was repeated for a control group of patients who were discharged from the same medical ward over a 2-week period in November 2019 and received clinical pharmacist discharge review but no pharmacy input into the DS.
Errors were assessed as high risk using a modified APINCH system which excluded antimicrobials.9
Antimicrobials were excluded to align with institutional policies on high-risk medicines. Error types were cate- gorised as per the Victorian Health Incident Manage- ment System.10 All data was stored in a Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA) spreadsheet with statistical analysis undertaken using R Version 3.6.3 (R Foundation, Vienna, Austria). Statistical significance was assessed using chi-square tests. This study was registered with the hospital human research ethics committee as a quality assurance activity.
The intervention and control groups were composed of 22 intervention patients and 31 control patients (Table 1). Patients who received the intervention were less likely to have one or more medication errors on their DS (any: 4% vs 84%, p < 0.01; high-risk: 0% vs 29%, p 0.05).
The intern pharmacist made a total of 77 recommen- dations during the intervention period, all of which
Table 1 Patient details
Control, N = 31 Intervention, N = 22
Age Mean 74 76 Median 80 80 Range 24–94 50–96 Standard deviation 17.7 14.2
Discharge medication (number) Mean 9.2 9.8 Median 10 9 Range 1–19 5–18 Standard deviation 4.9 4.1
Sex (female) Number 13 10 Percentage 42% 45%
� 2022 Society of Hospital Pharmacists of Australia. Journal of Pharmacy Practice and Research (2022) 52, 454–457
Improving discharge summaries 455

were actioned by medical staff. Six recommendations (8%) related to high-risk medications. The median time to undertake the first review was 4 min (interquartile range: 2.25–5) and the second review was 1 min (in- terquartile range: 1–1).
Our study demonstrated that once intended discharge medications are determined by prescribers and clinical pharmacists, modest reconciliation-based interventions at the point of discharge can result in significant improvements in the accuracy of medication information in DSs.
In line with previous studies, this research reinforces the notion that collaborative interventions at the point of discharge yield greater accuracy in DSs. Two other significant studies were conducted assessing improved DS medication accuracy at Australian hospitals. Tong et al. and Elliott et al. found DSs with one or more errors were lower in patients receiving interventions (all errors: 15% [intervention] vs 61.5% [control] p < 0.01; clinically significant errors: 15% [intervention] vs 43% [control] p < 0.001, respectively).7,4 Both hospitals uti- lised the same electronic medication management sys- tem (Cerner) in use at our institution, although the interventions required a pharmacist. The time taken to undertake the task was comparable to that reported by Elliott et al. (5 min), although our study did not review the communication of other medication-related informa- tion (such as medication changes).4
Informal feedback from the medical staff participating in this intervention was positive and staff asserted that the intervention should be continued on an ongoing basis. Medical staff did note that interruptions during busy times to correct DS discrepancies could be disrup- tive and that this should be avoided if possible.
Although we found the intervention described in this study did not require a registered pharmacist, the time requirement for completion was short. Given the time and cost requirements to recruit and train staff for this specific task, the intervention may be better suited as an addition to existing clinical pharmacists’ responsibilities. Alternatively, this task may be suitable for a pharmacy technician undertaking extended roles. This decision may differ between healthcare providers depending on patient demographics, existing pharmacy services, and available resourcing.
The baseline rate of medication errors in the control group DSs was comparable to other studies undertaken in older general medicine populations.2,3,6,7 The most common errors identified (omission and duplication) were similar to those obtained in other studies and in our context was likely a result of incorrect utilisation of electronic medication reconciliation decision support tools.2,3,6,7
The limitations of our study include the small sample size, lack of randomisation or blinding, differing dates for control and intervention periods, and the fact that it was undertaken at a single site. However, we feel that the overwhelming improvement in DS accuracy in our intervention group warrants further exploration of this additional procedural step. Although the intervention was procedural in nature, further research is required to determine whether similar benefits would occur through the use of staff without formal healthcare training. Additionally, we did not investigate whether DS errors resulted in patient harm or other adverse outcomes, nor did we review other aspects of DSs, such as communi- cation of medication changes; these remain areas requir- ing further study. Finally, the intervention described in this study is dependent on pharmacist-based clinical review and reconciliation on discharge and therefore may not be suitable in settings where clinical pharmacy services are not consistently provided. It is for this rea- son that further work at our institution is now focused on improving the EMR electronic decision support func- tionality because this will provide benefits to all patients in all contexts, including those who may not currently be prioritised for clinical pharmacy services.
In conclusion, DSs frequently contain medication errors, and even modest reconciliation-based interven- tions may result in a significant reduction in errors.
Table 2 Details of errors
Control Intervention
Error type Omitted drug or dose 43 0 Unnecessary drug 38 0 Duplicated dose 22 0 Wrong dose/strength 10 0 Wrong frequency 7 0 Wrong form of medication 5 0 Wrong duration 2 0 Wrong time 0 2 Total 127 2
High-risk medication errors – classification Potassium and parenteral electrolytes 3 0 Insulins 0 0 Narcotics and other sedatives 5 0 Chemotherapy 0 0 Heparins and other anticoagulants 6 0 Total 14 0
Journal of Pharmacy Practice and Research (2022) 52, 454–457 � 2022 Society of Hospital Pharmacists of Australia.
456 Nguyen et al.

The authors have no acknowledgements.
The authors have no conflicts of interest to declare.
All authors contributed to the research project design and concept. AN conducted data collection and partici- pated in the intervention. All authors contributed to data analysis and writing of the manuscript. All listed authors comply with the Journal’s authorship policy
This publication was registered with the Eastern Health Human Research and Ethics Committee as a Quality Improvement Activity prior to commencement (QA20-070).
Research data are not shared.
1 Australian Commission on Safety and Quality in Health Care. National Safety and quality health service standards. September 2012. Sydney: ACSQHC; 2012. Available from .
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3 Graabæk T, Terkildsen BG, Lauritsen KE, Almarsd�ottir AB. Frequency of undocumented medication discrepancies in discharge letters after hospitalization of older patients: A clinical record review study. Ther Adv Drug Saf 2019; 10: 1–8.
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8 Taylor G, Leversha A, Archer C, Boland C, Dooley M, Fowler P, et al. Overview: Standards of practice for clinical pharmacy services. J Pharm Pract Res 2013; 43(2 SUPPL): 91–3.
9 Australian Commission on Safety and Quality in Health Care. APINCHS classification of high risk medicines. ACSQHC. Available from . Accessed December 2021.
10 Safer Care Victoria. Victorian health incident management system (VHIMS). State of Victoria; 2018. Available from . Accessed December 2021.
Received: 13 March 2022 Revised version received: 05 August 2022 Accepted: 11 August 2022
� 2022 Society of Hospital Pharmacists of Australia. Journal of Pharmacy Practice and Research (2022) 52, 454–457
Improving discharge summaries 457

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