A Retrospective Audit on the Accuracy of Medication Related Information in Discharge Summaries from Acute Geriatric Units, and Evaluating the Impact of Pharmacist Intervention at the Time of Discharge


  • Teagan Phillips
  • Natasha Mallam
  • Alexandra Brooks
  • Gauri Godbole
  • Jennifer Moroney




discharge summaries, medication safety, geriatrics, pharmacy, student-led research, pharmacist intervention


Background: Medication related discrepancies in hospital discharge summaries are widespread and concerning.
Aim: To assess the impact and severity of pharmacist interventions (PI) in the reconciliation of discharge summaries, and to determine if a relationship exists between the total PI and the patients’ discharge destination. Secondary aim is to analyse trends in the documentation of medication changes made in hospital, and to identify if a correlation exists between the quality of documentation and the patients’ discharge destination.
Method: A retrospective audit of discharge summaries from two acute geriatric wards in a district hospital was conducted over a three-month period. PI were stratified according to severity. The number of new, ceased and changed medications were recorded, and assessed to determine if each medication change was adequately documented. Results: The study found 278 PI from a total of 230 discharge summaries, rated 34.7% minor, 23.4% moderate and 39.2% severe PI. The study found that 56.4% new medications, 95.4% ceased medications and 49.6% changed medications were accurately documented. Significant differences were identified in the documentation of new and ceased medications (p<0.00001), new and changed medications (p<0.00001) and ceased and changed medications (p=0.00314). The documentation of total medication changes was identified to have no relationship to the discharge destination (p=0.71).
Discussion: This audit reiterates the importance of pharmacist input in medication reconciliation at discharge, particularly for patients in geriatric units. The study outlines opportunities to improve the documentation of medication changes in the discharge summaries with an aim to improve transitions of care.


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