When a patient is discharged from hospital back to the community, there is increase possibility of medication error. To help minimize this risk of harm, a systematic procedure should be implemented for receiving discharge prescriptions.
When a discharge prescription is received, please ensure a copy is scanned into the patient’s file under the “Paperclip” tab and labelled “Hospital Discharge”. This will allow for quick access for future review.
Perform a medication reconciliation. Compare the patient best possible medication record from our software with the discharge prescription. Ensure that any new medications prescribed for patients are appropriate. Some questions to be considered may include:
• Is this medication appropriate for my patient considering the patient’s age, lifestyle, medical conditions, and current medications?
• Is the medication indicated for my patient?
• Is the dosage appropriate for my patient?
• Do any of these medications pose a risk to the patient?
• Is this medication going to help my patient get better?
• Are there any potential unintended dosage changes?
• Will there be any possible drug interactions?
• Are there any duplicate therapies?
Differences or discrepancies between these two sources of information are identified and resolved. Any questions should be resolved by consulting either the discharging physician, hospital pharmacy, the patient themselves, the patient’s family, or even the patient’s primary care physician to ensure the medications prescribed are appropriate.
Update the patient’s file with the reconciled list and communicate this reconciled list to the patient and others involved in the circle of care.
Document the medication reconciliation in the patient’s file under the “Consult” tab. Document your interpretation, decisions, and actions. Documentation should allow another pharmacist to understand what has taken place, why changes were made and the reason behind the actions. If a hospital Medscheck was performed, scan copies of the required forms into the “Paperclip” tab and label as “Hospital Discharge Medscheck”.