The Pharmaceutical Journal
Vol 268 No 7182 p81-86
26 January 2002

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Discharge information needs to be improved to prevent prescribing errors

Information transfer between secondary and primary care needs to be improved to prevent drug errors. Although electronic transmission of information offers a solution to the problem, its success should not be assumed, researchers say.

Ann Coleman, pharmaceutical adviser, Calderdale and Kirklees Health Authority, and colleagues audited discharge and out-patient letters over a four-week period and compared them with patient notes and repeat prescription records to identify errors. They found that quality of discharge information was often inadequate.

Among 232 discharge advice notes, information to continue appropriate prescribing was missing in 11 per cent of cases. Information that was most commonly absent included dose/frequency, course length, strength of steroid inhalers and inhaler formulation. Of 124 outpatient letters, further information was required in 25 per cent of cases.

The researchers also assessed errors made in general practice when information was transcribed to practice records. The main problems identified were old medication not stopped, duplication and recommended changes not being implemented.

To reduce the problems, they suggest:

• Better training for house officers in completing discharge advice notes
• Standardising the format of discharge letters to include expected duration of therapy and a list of all medication stopped during admission

They also note the role that community pharmacists can play. Previous research had shown that a letter sent simultaneously to the patient's nominated community pharmacist on discharge can reduce discrepancies. "This is probably due to the pharmacist correcting issues before supply, which untrained practice staff may not have identified," they say (Journal of Social and Administrative Pharmacy 2001;18:226).

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