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Specialist Pharmacy Service
Medicines Use and Safety P S
Collaborative audit and service evaluation across England on the quality of medication related information provided when transferring patients from secondary care to primary care and the subsequent medicines reconciliation in primary care
Lead: Chetan Shah
Previously - Associate Director, Medicines Use and Safety
Currently - Chief Pharmacist, Hertfordshire Partnership University NHS Foundation Trust
Presented by : Jane Hough
Associate Director, Medicines Use and Safety, Specialist Pharmacy Service
Winner: Dressings, PrescQIPP Innovation awards 2013; Winner: RPS Pharmaceutical Care award 2013;
Finalist: HSJ Improving Safety and Quality in Primary Care 2015; Winner: UKCPA/Guild Conference Best Poster award 2013

2. S P S
Medicines Use and Safety
Drivers for the audit
NHS England Patient Safety Alert on the risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care
NICE MO 1.3.3: In primary care, carry out MR for patients discharged from hospital or another care setting. This should occur within 1 week of the GP practice receiving the information
Royal Pharmaceutical Society. Keeping patients safe when they transfer between care providers – getting the medicines right, 2012
Royal College of Physicians. Standards for the clinical structure and content of patient records, 2013.
Department of Health. The discharge summary toolkit, 2011

3. S P S
Medicines Use and Safety
Aims of the audit
To assess the quality of information regarding medicines within discharge summaries provided by secondary care (Acute, Mental Health and Community Services)
To determine whether GPs have correctly acted upon the information provided regarding medicines in the discharge summaries within 7 days of receiving the discharge information

4. S P S
Medicines Use and Safety
Audit methodology (1)
CCGs in England invited to participate via NICE and MUS networks
Each CCG to audit as many patient discharges from the past three months as practical (minimum 1 patient discharge audit per 50,000 population)
Data collection January 4th to 29th January 2016
Data collected in GP surgery by primary care (practice/CCG/CSU) pharmacist
Compared discharge information on medicines with preadmission medicines looking for changes and documented reasons
No patient identifiable data was collected, and for the purposes of any publications and reports all data will be anonymised

5. S P S
Medicines Use and Safety
Audit methodology (2)

6. S P S
Medicines Use and Safety
Data collection
Demographic and background information in discharge summary e.g Patient information, GP information, length of stay, reason for admission
Quality of information on discharge summary/TTA e.g allergies, prescribing standards
Changes to medication e.g documentation of medicines started, stopped and doses changed with reason
Reconciliation in primary care e.g was the information in the discharge summary/TTA acted upon, which staff personnel acted on the information
Contact details e.g discharge summaries screened/clinically reviewed by a pharmacist

7. S P S
Medicines Use and Safety
Audit results

8. Collaborative audit results (1)P S
Medicines Use and Safety
National Audit Results
Total number of patient discharge summaries audited
1,454
Total number of medicines prescribed across all discharge summaries audited
10,038
Total participating CCGs 43
Total trusts/private providers audited
66/8
Median age of patients audited (n=1419)
72 years (range 0 – 102 years)
Gender of patients audited (n=1433)
Female = 53%
Male = 47%
Median length of inpatient stay (n= 1454)
4 days (range 0 – 208 days)
Median length of time before GP received the discharge summary/TTA (n=1434)
Same day as discharge (range 0 – 38 days)
Route of admission (n=1454)
Unplanned – 78.6%
Planned – 21.4%
Allergy status documented on discharge summary (n=1453)
75.8%

9. Collaborative audit results (2)P S
Medicines Use and Safety

10. Collaborative audit results (3)P S
Medicines Use and Safety

11. Collaborative audit results (4)P S
Medicines Use and Safety
New medicines started whilst an inpatient
National Audit Results
Percentage of patients who had at least one new medicine started whilst an inpatient (n=1454)
79% (1146 patients)
Total no of medicines started across patients audited (n=1454)
3,164
Mean of 2.18 medicines started per patient audited
Of the newly started medicines (n=3164) what proportion had a reason documented?
49%
Were the newly started medicines incorporated / actioned on the GP prescribing system? (n=1146)
Yes = 53%
No = 13%
No action required* = 34%
*for example where antibiotics, laxatives, analgesics may have been prescribed as a short course of therapy

12. Collaborative audit results (6)P S
Medicines Use and Safety
Medicine dose changes whilst an inpatient
National Audit Results
Percentage of patients who had the dose of at least one of their medicines changed whilst an inpatient (n=1454)
23% (336 patients)
Total no of medicines that had a dose change across patients audited (n=1454)
477
Mean of 0.32 medicines that had a dose change per patient audited
Of the medicines with dose changes what proportion had a reason documented
39%
Were the medicines that had dose changes incorporated / actioned on the GP prescribing system? (n=336)
Yes = 64.9%
No = 34.5%
Data unavailable = 0.6%

13. Collaborative audit results (5)P S
Medicines Use and Safety
Medicines stopped whilst an inpatient
National Audit Results
Percentage of patients who had at least one medicine intentionally stopped whilst an inpatient (n=1454)
27% (388 patients)
Total no of medicines intentionally stopped across patients audited (n=1454)
738
Mean of 0.51 medicines intentionally stopped per patient audited
Percentage of patients who had at least one medicine omitted on their discharge summary/TTA (i.e medicines they normally took prior to admission but which were unlikely to have been stopped) (n=1454)
33%
Total no of medicines omitted across patients audited (n=1454)
1565
Mean of 1.1 medicines omitted per patient audited
Of the medicines intentionally stopped (n=738) what proportion had a reason documented?
57%

14. Collaborative audit results (7)P S
Medicines Use and Safety

15. Collaborative audit results (8)P S
Medicines Use and Safety

16. Collaborative audit results (9)P S
Medicines Use and Safety

17. Collaborative audit results (10)P S
Medicines Use and Safety

18. Collaborative audit results (11)P S
Medicines Use and Safety
Medication reconciliation in primary care
National Audit Results
For medicines that were Started/Stopped or Doses Changed during the hospital inpatient stay, were the changes actioned by the GP within 7 days of the discharge being received? (n=1438)
Yes = 45.5%
No = 12.5%
No action required = 42%
At least one change was actioned Incorrectly for 5.5% of patients 
Who carried out the medicines reconciliation within the GP surgery for the discharge summaries received? (n=1441)
 * in these datasets it was difficult to ascertain why these options had been chosen and therefore is difficult to draw conclusions
GP = 51.5%
No requirement to undertake Medicines Reconciliation* = 15.1%
Unable to identify = 7%
CCG/Practice Pharmacist = 6.6%
Not undertaken* = 5.7%
Practice Receptionist = 5.6%
Practice Nurse = 0.5%
Practice Manager = 0.1%
Other = 8.1%
Was the medicines reconciliation process READ coded? (n= 1234)
Yes =17%
No = 83%
Was there any evidence that the patient was involved in the medicines reconciliation by the GP surgery? (n=1261)
Yes =16.5%
No = 83.5%

19. Main Report Conclusions
Medicines Use and Safety
Communication on medication changes when patients transfer from secondary care to primary care still requires significant improvement
Secondary care providers to consider including the contact details of the reviewing/screening pharmacist so primary care clinicians can contact them. Secondary care providers to utilise Summary Care Records (SCR) to ensure that MR at admission is robust
CCGs and secondary care providers should collaborate to review the local hospital discharge template to ensure that it meets the needs of all involved, is in line with the standards set by the RPS and Academy of Royal Colleges
GP practices need clear processes for how information provided on discharge summaries/TTAs is managed once received eg individuals responsible for reviewing medicines on discharge summaries and actioning on the GP records
Consideration should be given to the role of clinical Pharmacist’s in GP practices reconciling medicines post discharge from secondary care
CCGs may with to develop or revise CQUINs to help drive quality improvement of discharge communication by secondary care as previously recommended by the CQC

20. Participating CCGs Barnet Brent Central Manchester City and Hackney
Coastal West Sussex
Cumbria
Doncaster
Ealing
East Sussex
Eastbourne
Fylde and Wyre
Haringey
Harrow
Hartlepool and Stockton
Hastings and Rother
Herefordshire
Hillingdon
Inner North West London
Isle of Wight
Islington
Kingston
Leeds South and East
Merton
Mid Essex
Newcastle and Gateshead
North Tyneside
North West Surrey
Oxfordshire
Portsmouth
Salford
Sheffield
Slough
South Gloucestershire
South Reading
South Tees
Surrey Downs
Surrey Health
Waltham Forest
West Essex
Wigan
Windsor, Ascot and Maidenhead
Wokingham

21. 66 Trusts & 8 private providers audited
8 private providers 1 to 6 patients audited
3 trusts over 100 patients audited (North Bristol, North Cumbria, Sheffield)
3 trusts 50 to 100 patients audited (Morecambe Bay, Salford, University Hospital Bristol)
23 trusts 10 to 49 patients audited (Barts Health, Blackpool, Bolton, Doncaster, East Sussex, Frimley, Gateshead, Hillingdon, Homerton, Imperial, IOW, LNWHT, Mid Essex, Newcastle, Oxford, Princess Alexandra, Royal Free, Royal Berks, Royal United Bath, Sheffield Children’s, Surrey and Sussex, UCLH, Western Sussex

22. 66 Trusts audited 16 trusts 5 to 9 patients audited
Ashford St Peters, Brompton, Cambridge, Central Manchester, Cumbria Partnership, Epsom & St Helier, Kingston, Lancashire Teaching, Leeds, North Tees, Pennine Acute, Portsmouth, Rotherham & Doncaster. South Tees, Wrighton, Wigan & Lee and Wye Valley
21 trusts less than 5 patients audited
Avon & Wilts MH, Barking, Brighton, Chelsea & Westminster, CNWL, E & N Herts, Gloucester, Greater Manchester West MH, GSTT, Kings, North Essex, Royal National Orthopaedic, Royal Surrey County, Solent, South Tyneside, Southampton, St George’s, South Manchester, West Herts, West Mid.

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Medicines Use and Safety
Acknowledgements
The members of the steering group that helped develop, pilot and validate this audit are detailed below. MUS would like to sincerely thank them for their time, support and expertise
Gwen Hopkins - Inner NW London CCGs
Brian Mackenna - Islington CCG
Helen Marlowe - Surrey Downs CCG
Louisa Griffiths - Oxfordshire CCG
Theodora Michael - Brent CCG
Michelle Liddy - National Institute of Clinical and Healthcare Excellence
Dr Bryony Dean Franklin - Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust
Dr Zoe Aslanpour - University of Hertfordshire
Dr Sara Garfield - Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust
Louise Maunick - Medway NHS Foundation Trust
Jane Hough – Medicines Use and Safety, NHS Specialist Pharmacy Service
Dr Carina Livingstone – Medicines Use and Safety, NHS Specialist Pharmacy Service
Julia Wright – Medicines Use and Safety, NHS Specialist Pharmacy Service
Samantha Xavier-James – Medicines Use and Safety, NHS Specialist Pharmacy Service

24. Questions? My contact details jane.hough4@nhs.netP S
Medicines Use and Safety
Questions?
My contact details
Further details of the audit including methodology
and medicines reconciliation resources can be found on Specialist Pharmacy Service
Website at