Evaluation of the pharmacist role in discharge from hospital

When patients are discharged from hospital it is vital that the information regarding their medication is provided to the General Practitioner (GP) as accurately and efficiently as possible. However errors frequently occur and the NHS is currently investigating how to improve discharge systems, one approach is to use pharmacists to write discharge prescriptions or To Take Out (TTOs). The aim of the audit was to compare discrepancies on TTOs (To take out) between different transcribers: doctors, pharmacists and nurses and identify factors which are predictors of discharge discrepancies. Discharge summaries written by different transcriber groups from three study wards at one hospital were selected. Discrepancies were identified by comparing the unauthorised TTO (TTO prior to final pharmacy check) to authorised TTOs, medical notes and prescription chart. Discrepancies were classified according to the CHUMS classification procedure. Logistic regression was used to identify predictors of discrepancies. Two hundred and fifteen TTOs were included in the audit written by pharmacists, doctors and nurses (n= 85, 81 and 49, respectively). Nearly 50% of TTOs contained at least one discrepancy, the most common of which was omission of a medicine. The significant predictors of discrepancies were if a TTO was written by a nurse or a doctor or if there was more than three hours between an unauthorised TTO being authorised (Odds ratios were 3.45, 2.26 and 3.88, respectively). Overall this study demonstrates the using pharmacist transcribers is at least as safe as previous systems and is unlikely to introduce additional discrepancies. Alternative approaches which support the healthcare team to work closer together at the time of discharge should reduce delays authorising the TTO and reduce discrepancies