Discharge of Medicine Service (DMS) Standard Operating Procedure

Purpose

To ensure the safe and effective management of discharge medicines for patients, in accordance with the NHS Discharge Medicines Toolkit, to support continuity of care and patient safety.

Scope

This SOP applies to all pharmacy staff involved in the discharge process this includes:

Pharmacists: Ensure accurate medication reconciliation, provide patient education, and manage the discharge medication process.

Pharmacy Technicians: Assist with medication preparation and labelling. Definitions

Discharge Medicines: Medications provided to patients upon discharge from a healthcare facility.

Medication Reconciliation: The process of comparing a patient’s medication orders to all of the medications that the patient has been taking.

Procedure
1. Check for new referrals (Stage 1)

Check for new referrals via the premises-specific NHS mail account at appropriate intervals throughout each day the pharmacy is open. It is suggested to do this first thing in the morning and then every hour after. Each referral must be completed within 72hrs of receipt.

A clinical review should undertaken by the community pharmacist following receipt of a patient referral. The community pharmacy team may contact the referring NHS trust contact or the PCN pharmacy team to discuss any concerns (eg an important medicine the patient usually takes is omitted on the discharge referral) and to seek clarification about the discharge referral. Keep in mind high-risk patients which might include:

People taking more than five medications, where the risk of harmful effects and drug interactions is increased.

Those who have had new medicines prescribed while in hospital.

Those who have had medication change(s) while in hospital.

Those who have experienced myocardial infarction or a stroke due to likelihood of new medicines being prescribed.

Those who appear confused about their medicines on admission/when getting ready for discharge, and have already needed additional support from a healthcare professional.

Those who have help at home to take their medications.

Those patients who have a learning disability.

2. Medication Reconciliation and Review

Initiation: Upon receipt of a discharge prescription (Stage 2), review the patient’s medication history and current medication orders.

Reconciliation: Compare the discharge medications with the patient’s pre-admission medication list. Identify and resolve discrepancies (e.g., omissions, duplications, interactions).

Consultation: Collaborate with the prescribing medical team to address any issues identified during reconciliation.