Collecting & checking

• Clinical check by a pharmacist

The pharmacist will look for any clinical information or actions required from the discharge referral information. Examples of some of the issues that might arise include:

• Changes to quantity or frequency of prescription. For example, are there any instructions for the GP to prescribe smaller quantities of benzodiazepines or opioids at risk of abuse (such as weekly prescriptions)?
• Are changes to dose, formulation, frequency of administration, and discontinued medicines explained in the discharge information?
• Have any medicines been continued that should have been stopped when the patient left hospital? For example, antibiotics, low molecular weight heparin, post-operative pain relief, laxatives. Are there any potential consequences of discontinued medicines being stopped? For example, a proton pump inhibitor being continued indefinitely after an NSAID has been stopped.

• Comparison of the patient’s medicines on the discharge list against the medicines on the PMR (pre-admission)

Consider any clinical issues arising from differences between the medicines on the discharge list compared to the medicines that the patient was taking previously from the PMR. This should include all medicines, not just those taken orally. The summary care record may need to be referred to.

Note that a pharmacy technician may undertake the comparison of pre- and post-discharge medicines, but it is the pharmacist’s responsibility to identify any potential clinical issues arising from any discrepancies or changes.

Previously ordered prescriptions for the patient should be identified and compared to see if they are still appropriate. These may have been ordered from the GP practice, be somewhere in the dispensing process or be dispensed and awaiting collection or delivery.

• Check that the first post-discharge prescription received reflects changes 

By the time the community pharmacy receives the first prescription for the patient after discharge, the GP should have had time to make any necessary changes to the medicines, in line with the NHS Trust discharge information. Sometimes this doesn’t happen, particularly for patients using medicines compliance aids/monitored dosage systems – these patients often only receive a seven-day supply on discharge – or for electronic repeat dispensing prescriptions that are released to the pharmacy at regular intervals. It is important for the pharmacist or pharmacy technician to check that the prescription received reflects any appropriate changes.