Pharmacy Department, Hertfordshire Partnership University NHS Foundation Trust, Hertfordshire, UK.
Medicines Use and Safety, NHS Specialist Pharmacy Service, London, UK.
Eur J Hosp Pharm. 2020 May;27(3):137-142. doi: 10.1136/ejhpharm-2018-001613. Epub 2018 Sep 26.
Medicines reconciliation is an effective way of reducing errors at transitions of care. Much of the focus has been on medicines reconciliation at point of admission to hospital. Our objective was to evaluate medicines reconciliation after discharge from hospital by assessing the quality of information regarding medicines within discharge summaries and determining whether the information provided regarding medicines changes were acted on within 7 days of receiving the discharge information.
A retrospective collaborative evaluation of medicines-related discharge information by Clinical Commissioning Group (CCG) pharmacists using standardised data collection tools. Outcomes of interest included compliance with national minimum standards for medication-related information on discharge summaries, such as allergies, changes to medication regimen, minimum prescription standards, for example, dose, route, formulation and duration, and medicines reconciliation by the primary care team. Data were analysed centrally.
43 CCGs covering each of the four National Health Service regions in England participated in the study and submitted data for 1454 patients and 10 038 prescribed medicines. The majority of medication details were stated in accordance with standards with the exception of indication (11.7% compliance), formulation (60.3% compliance) and instructions of ongoing use (72.5% compliance). Documentation about changes was poor: 1550/3164 (49%) newly started medicines, 186/477 (39%) dose changes and 420/738 (57%) stopped medicines had a reason documented. Changes were not acted on within 7 days of receiving the discharge information for 12.5% of patients.
Our evaluation revealed overall good compliance with discharge medication documentation standards, but a number of changes to medicines during hospitalisation were not fully communicated or documented on the discharge summary or actioned in the general practice after discharge.
药物重整是减少医疗转衔差错的有效方法。目前大部分研究重点都集中在入院时的药物重整。我们的目的是通过评估出院小结中药物相关信息的质量，以及确定在收到出院信息后 7 天内是否对提供的药物变更信息采取行动，来评估出院后的药物重整情况。
临床委托组药剂师使用标准化数据收集工具，对药物相关出院信息进行回顾性协作评估。主要观察指标包括出院小结中与药物相关的信息是否符合国家最低标准，如过敏、药物治疗方案的变更、最小处方标准（例如剂量、途径、剂型和持续时间），以及初级保健团队是否进行了药物重整。数据由中央进行分析。
英格兰四个国民保健服务区域的 43 个临床委托组参与了该研究，并提交了 1454 名患者和 10038 种处方药物的数据。除了适应证（符合率 11.7%）、剂型（符合率 60.3%）和持续使用说明（符合率 72.5%）外，大多数药物信息都符合标准。关于变更的记录很差：新开始的药物中有 1550/3164 种（49%）、剂量变化有 186/477 种（39%）、停止使用的药物有 420/738 种（57%）记录了原因。在收到出院信息后 7 天内，12.5%的患者未对变更采取行动。
我们的评估结果显示，出院药物记录标准总体上符合要求，但在住院期间有一些药物变更未在出院小结中全面传达或记录，或在出院后未在全科医生处进行处理。
