Discharge Medication Reconciliation
Discharge Medication Reconciliation
What is Discharge Medication Reconciliation?
Virtual Pharmacist provides a comprehensive discharge medication reconciliation service. Our cohort of expert pharmacists compare pre-admission and post-discharge medication regimens, ensuring all hospital-initiated changes are accurately implemented and fully documented.
This service ensures appropriate monitoring and follow-up to improve patient safety and care following hospital discharge.
How Will This Help My Practice?
Enhances patient safety and safeguarding
Reduces clinical risk and prevents hospital re-admissions.
Identifies & resolves all discrepancies
Avoiding inappropriate or non-formularly prescribing.
Prevents unintentional re-prescribing
Decreases the risk of medication errors from hospital-only medications.
Reduces GP workloads
By actioning medication changes and working through discharge letters.
Supports CQC compliance & medicines governance
Full SNOMED coding, documentation and safety procedures.
Alignment with practices and ICBs
Ensuring all medication changes are suitable and justified.
“The team is consistently reliable. Phones are always answered and emails come back the same day. It’s made a real difference to how we run our medication reviews.”
“Fast email replies and always there when we need clinical input. The pharmacists fit straight into the team and just get on with the work.”
“Excellent service from start to finish. Easy to reach, quick to reply, and they clearly know NHS workflows inside out. We couldn’t recommend the team more highly.”
How Does Virtual Pharmacist Work?
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Frequently Asked Questions
What does discharge medication reconciliation involve?
Discharge from a hospital stay is a high-risk period for patients. This essential service involves our pharmacists performing crucial reviews, reconciliation and safe actioning following hospital summaries.
Pharmacists review several aspects of a patient’s medication regimen:
- Checking pre-admission medications against discharge prescriptions
- Identifying new medications started or stopped during the hospital stay (and confirming if stopped items should remain so)
- Noting any changes in dose or formulation
- Reviewing temporary prescriptions, such as antibiotics
- Assessing shared-care drugs that require GP agreement
- Checking the monitoring requirements for any high-risk medications
What types of discharges do you manage?
Our pharmacists handle the full spectrum of discharges from secondary care. This includes A&E attendances, inpatient, mental health inpatient and crisis services, maternity or postnatal units, community hospitals and rehab facilities, surgical and medical specialties, and high-risk discharges (such as renal and cardiology).
How do you manage high-risk medications on discharge?
The team of virtual pharmacists complete many tasks related to high-risk medications, including DOACs, insulin, controlled drugs, antipsychotics, and more. Our pharmacists work to verify monitoring, review interactions, check suitability, and arrange blood or blood pressure tests as part of this high-risk management. They will also provide patient follow-up, helping to reduce clinical risk and re-admissions.
How do you address unsafe or unclear information from hospital discharge summaries?
Discharge summary notes sometimes come with information that can prevent optimal care. In these instances, our pharmacists work hard to liaise with secondary teams for clarification, or escalate to GP practices where clinical oversight is required. This prevents the unsuitable long-term continuation of acute hospital medicines, during what is a high-risk period.
Which systems does this service use?
Our pharmacists complete these monitoring and follow-up services using systems such as Eclipse, Ardens, ScriptSwitch, and OptimiseRx. These tools help our team to:
- Identify risks when new medicines are added to the system
- Check formulary compliance
- Flag any medicines interactions of contradictions
- Highlight any cost-effective alternatives, where appropriate
- Support monitoring actions for high-risk medications
