Complete the notes below. Write ONE WORD AND/OR A NUMBER for each answer.
Discharge Medication Check
Why discharge is a high risk stage
Patients are given written (31) ______ about changes to their medication.
Problems are more common among patients with long term (32) ______ conditions.
What the process involves
Staff produce the most accurate medication list and compare it with discharge prescriptions.
Best practice is to complete the final check within (33) ______ hours of discharge.
Types of error
(34) ______, a regular medicine is missing from the discharge list.
Incorrect (35) ______, the drug is listed but the amount or frequency is wrong.
Duplication may occur when brand names and generic names are both used.
A hospital programme
One source checked is the (36) ______ list.
Key features of the programme
problems often arise at (37) ______ changes
high risk medicines include (38) ______
patients are given a weekly (39) ______ chart
readmissions fell by (40) ______ percent
Keys
31 information 32 chronic 33 24 34 omission 35 dosage 36 GP 37 shift 38 insulin 39 dose 40 12
Transcripts
Part 4: You will hear a lecturer talking about Discharge Medication Check.
Today I want to talk about medication reconciliation at hospital discharge. It sounds administrative, but it affects safety in a very direct way. Discharge may seem routine. A patient receives a prescription, some papers, and a short explanation, then goes home. In reality it is a transfer of responsibility from the hospital team to the patient and primary care. At any transfer, details can be lost, and medicines are where that loss often shows up.
To begin with, consider what happens during admission. Medicines are often changed. A drug may be stopped because it clashes with a new treatment. Another may be added temporarily to control symptoms. Doses may be adjusted as the patient improves, and some items may be replaced with hospital alternatives. When the patient leaves, they are given written information about these changes, but it may be unclear. The language can be technical, the list may not match what the patient was taking at home, and there may be more than one document. If the patient receives two lists that differ by even one item, they may guess which is correct or combine them.
These problems are especially common for patients with long term chronic conditions. They may already have complex routines and prescriptions from several places. A hospital specialist may alter one drug, while a general practitioner manages the long term list. Even if each change makes sense, the final set of instructions can be difficult to follow, especially when the patient is tired, anxious, or in pain.
Now I will explain what medication reconciliation involves. It aims to prevent that confusion. Staff produce the most accurate list of what the patient should be taking, then compare it with what is prescribed on discharge. The key is the comparison. It forces the team to spot differences and decide whether each one is intended.
Timing matters as well. Some staff aim to do the final check on the morning of discharge, because that feels efficient, but within 24 hours of discharge is usually better. If the check is done too early, later changes will be missed. If it is done too late, there is no time to fix errors.
Before I describe the programme, it is useful to be clear about the typical errors. One common error is omission. A regular medicine that should continue is missing from the discharge list. This can happen when a long term medicine was paused during acute treatment and then never put back. Another common error is the wrong dosage. The right medicine is listed, but the amount or frequency is wrong, for example once daily instead of twice daily. A third pattern is duplication. The same medicine appears twice because one entry uses a brand name and another uses the generic name. Patients may take both because they think they are different.
With that in mind, one hospital introduced a simple programme to reduce these problems, and it followed four steps.
First, staff built a reliable medication history. They did not rely only on the hospital record. They spoke to the patient and, when possible, to a family member who helps with medicines. They also checked community pharmacy records. Some teams started with the clinic summary, but the GP list was more reliable as a baseline for medicines taken before admission, especially for patients with several prescribers.
Second, staff identified mismatches and classified them. Many people assumed the main problem was the handover to primary care after discharge. However, the strongest factor in this hospital was poor communication during shift changes on the ward. Decisions were made during one shift, then not recorded clearly enough for the next team. By the time discharge paperwork was prepared, a dose change could look like a mistake, or an intended restart could be missed.
Next, the programme prioritised high risk medicines. The team did not treat every discrepancy as equally urgent. Anticoagulants were one example. Another key group was insulin, because small dosing errors can cause rapid harm, and patients may not notice a mistake until symptoms appear.
Finally, the programme focused on patient understanding. A correct list is not enough if the patient cannot follow it. Staff used teach back by asking the patient to explain the plan in their own words. If the explanation was unclear, staff corrected it and checked again. Patients were also given a weekly dose chart showing what to take at different times of day, which reduced reliance on memory at home.
To finish, the hospital evaluated the programme. Among patients taking multiple medicines, 30 day readmissions fell by 12 percent after the system was introduced. The point is not that all readmissions are preventable, but that fewer returns were caused by medication confusion, and that is a practical win for patients and services.
