Cluster page — medicines optimisation
Medicines reconciliation after hospital discharge
The intervention
Why 7-day reconciliation is the highest-leverage safety intervention in primary care
Hospital discharge is the single highest-risk transition of care a patient experiences. Up to 60% of adults discharged from acute care have at least one unintentional medicines discrepancy at the point of return to general practice: a dose change not communicated, a medicine started in hospital without a community prescription, a long-term medicine intentionally stopped that the practice re-issues by default, or a new high-risk drug initiated without monitoring transfer. These discrepancies are a leading preventable cause of 30-day re-admission.
NICE NG5 sets the standard: reconciliation within 7 days of receipt of the discharge summary, by a competent clinician (pharmacist, IP nurse or GP). At PCN scale this is delivered by the clinical pharmacist team using a pharmacy-technician triaged inbox workflow, with prescribing changes made under the pharmacist's IP scope of practice and coded with the agreed SNOMED set.
Reconciliation workflow
The 7-day reconciliation SOP
- Discharge summary received in EMIS/SystmOne practice inbox
- Pharmacy technician triages within 24 hours — flags high-risk cases (HRD changes, opioids, anticoagulants, transplant medicines)
- Clinical pharmacist completes record-level reconciliation against pre-admission medication list
- Prescribing changes made under IP scope; high-risk monitoring transfer arranged
- Patient contact (phone or video) for any clinically significant change
- GP partner copied on any change outside agreed scope
- SNOMED coding completed; outcome metric returned to PCN dashboard
Reconciliation KPIs
What good reconciliation performance looks like
Frequently asked questions
Reconciliation — FAQs
What is the NHS standard for post-discharge medicines reconciliation?+
Complete reconciliation within 7 days of discharge for every adult patient discharged from secondary or community hospital care. This is embedded in NICE NG5, the Discharge Medicines Service specification and most ICB local prescribing safety priorities.
Why does discharge reconciliation matter?+
Up to 60% of patients have at least one unintentional medicines discrepancy following hospital discharge — wrong dose, wrong drug, intentional change not communicated, or omitted resumption. These discrepancies are the largest single source of preventable medication-related re-admission in the over-65 cohort.
Who does discharge reconciliation in a PCN?+
Operationally most often the clinical pharmacist supported by the pharmacy technician. Technicians triage the discharge inbox, identify high-risk cases and prepare the record; the pharmacist completes the clinical reconciliation, makes prescribing changes and codes the work.
How does this link to the community Discharge Medicines Service (DMS)?+
DMS sits with community pharmacy and runs in parallel — the patient receives a medicines counselling intervention at their nominated community pharmacy after discharge. The primary care reconciliation is the clinical record-level activity. The two interventions are complementary, not duplicative.
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