1. S
East & South East England Specialist Pharmacy Services
East of England, London, South Central & South East Coast
Medicines Use and Safety P S
Improving safe and accurate transfer of medicines-related written discharge information
A pharmacy-led audit and service evaluation
Facilitated by Linda Dodds
Medicines Use and Safety Division, SPS
©East & South East England Specialist Pharmacy Services

2. Audit standards* 100% of discharge summaries should include:
Medicines Use and Safety P S
Audit standards*
100% of discharge summaries should include:
ｷ Details of the consultant caring for the patient
ｷ Known allergies
ｷ Appropriate follow-up actions for the GP
ｷ Accurate information on changes to medications (with reasons) during the admission
100% of prescription items should:
ｷ Be legible and unambiguous
ｷ Choice of medicine clear and correct
ｷ Dose, formulation, frequency and route clear and correct
*Taken from RPS guidance

3. Service evaluation Review of pharmacy contributions
Medicines Use and Safety P S
Service evaluation
Review of pharmacy contributions
Classification using 13 codes
Assessment of clinical impact of contributions
4 Levels (NPSA definitions)
Level 1: None/insignificant
Level 2: Low/minor
Level 3: Moderate
Level 4: Severe/major

4. S
Medicines Use and Safety P S
Methodology
Steering group to refine methodology & pilot the data collection forms
One day collection of data (minimum)
Choice of units/wards covered
Data collection inputted to electronic spreadsheet & returned to MUS
Local feedback of results
Feedback of summated data

5. Data analysis Variables
Medicines Use and Safety P S
Data analysis
Variables
Care area: medical, surgical, paediatric, CHS, MH
Type of admission: elective, nonelective, other
Type of discharge prescription: handwritten, electronic from handwritten, electronic from electronic

6. Overall data 45 organisations participated 2071 prescriptions screened
Medicines Use and Safety P S
Overall data
45 organisations participated
2071 prescriptions screened
1904 Acute; 89 CHS; 78 MH
673 ( 32%) prescriptions required no changes by pharmacy
2880 contributions
Average 1.4 contributions/prescription overall
Average 2.0 for prescriptions needing change

7. Prescriptions by care area
Steering group: keep it simple!
Majority of data from medical wards
Small numbers for CHS and MH

8. Prescriptions by type
83% of discharge prescriptions overall were electronic
65% (green) from handwritten chart
18% (red) fully electronic system
70% of discharges from urgent admissions
28% (543) elective admissions

9. Admission type by care area

10. Allergy status: Standard met in 83% scripts overall
Only standard where type of prescription made a clear difference (graph bottom right)

11. Consultant details by care area: Standard met in 94% scripts overall

12. Changes since admission fully recorded by prescriber: by care area
NB. Before pharmacy contribution
58% prescriptions met standard fully
27% fully recorded; 31% ‘not required’
18% partly recorded (some information in 76%)
Care area differences: % answered NO

13. GP actions fully documented by prescriber: by care area
NB. Before pharmacy contribution
Standard met for 69% of prescriptions
40% = yes all items; 29%= ‘not required’
31% = partly or not entered
Less differences by care area

14. But pharmacists were able to correct some of these omissions….
377 (13%) of contributions related to adding information on changed medicines
177 (6%) of contributions related to adding information on GP actions
Unclear whether additions were from ‘Partly’ to ‘fully’ or adding information when none before

15. Standards relating to prescription details
Prescription is legible and unambiguous
A prescription that required no pharmacy contributions:
32% met standard (ie prescriptions accurate as written; Overall 673 contributions to correct issues)
Choice of medication is clear and correct
In terms of contributions recorded: Omitted drug/wrong drug/ inappropriate addition/drug interaction codes
At least 54% met standard (Overall 946 contributions to correct)

16. Standards relating to prescription details
Dose/formulation/frequency/route clear
In terms of contributions recorded: Wrong or missing dose/ wrong or missing formulation or route/ wrong frequency/timing/duration code:
Overall 871 contributions
At least 58% met standard (871 contributions affected up to 42% of discharge prescriptions before pharmacy corrected)

17. Contributions analysis
2880 contributions overall
Overall av 1.4 per script
Av of 1.5 when screened on ward
Av of 0.9 when screened in the dispensary
Av 1.5 per nonelective script
Av 1.2 per elective script
Av of 1.4 whether handwritten, fully electronic or electronic from handwritten script

18. Graphical representation of contributions: all data

19. Table of contributions by care area

20. Acute results Top row (L to R) med/surg; Bottom row (L to R): paed/all

21. Contributions for CHS & MH scripts Top row (L to R) CHS, MH; Bottom row all data

22. Clinical impact of contributions-all data 33% of overall contributions, approx 1 in 2 scripts affected

23. Level 3&4 contributions by type of prescription & admission

24. Does pharmacy-led medicines reconciliation help?
20% scripts had no pMR (NB: 80% had had pMR)
56%: (A) pMR helped ensure discharge summary appropriate
15%: (B) pMR helped identify a problem needing resolution
8%: (C) pMR helped identify AND resolve a problem without need to contact prescriber
In 23% pMR directly improved accuracy of medication at discharge

25. Average number of prescribed items

26. Average time for clinical screen by care area

27. Average time for problem resolution by care area

28. Proportion of scripts screened by pharmacy (with caveats!!)
Asked for organisations to interrogate PAS data to establish the number of discharges for the ward areas audited
Data returned from 36 organisations
Many problems in getting correct number of discharges over allotted period- some uncertainty around data
For 1730 scripts reviewed, discharges recorded
Overall, it appears approx 55% of discharge prescriptions are actually seen by pharmacy depts

29. Summary Still much analysis to be done!
Pharmacy contributions contribute significantly to safe and accurate discharge information
Cost avoidance calculations will be attempted!
Data highlight areas where prescribers need to improve
E&T support from pharmacy?
Data illustrate added value of pMR (safety/time saving)
Is there any improvement in accuracy from all electronic prescribing?
Are the timings recorded accurate?
What about all those UNSCREENED prescriptions….?

30. Thank you! Steering group Participating organisations
Christine Masterson
Martin Webb & Liz Gull
Questions?