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Where are the weakest links?

A descriptive study of discrepancies in prescribing between primary and secondary sectors of mental health service provision

St Martin Hospital, East Kent Community Trust,

Sally-Anne Francis, Lecturer

Centre for Practice & Policy, School of Pharmacy, University of London, 29-39 Brunswick Square, London WC1N 1AX

Catherine Duggan, Director

Academic Department of Pharmacy, Barts and the London NHS Trust

Declaration of interest

None.

AIMS AND METHOD

To investigate the transfer of information regarding prescribed medication between primary and secondary care sectors. Patients aged 18-65 years, ready for discharge from hospital, were invited to participate. Prescribed medication was recorded from their hospital and general practitioner records. The significance of discrepancies identified between medication lists was assessed independently by four judges.

RESULTS

Discrepancies occurred for 39 out of 43 patients at each stage of medication information transfer. Discrepancies at the time of admission and following discharge occurred in 69% and 43%, respectively, of drugs studied. It was judged that harm would occur to the patient, should the discrepancy be reproduced, in 24% and 18%, respectively, of cases.

CLINICAL IMPLICATIONS

Discrepancies in the transfer of information regarding prescribed medication may result in harm to patients.

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				I. D Maidment, P. Lelliott, and C. Paton Medication errors in mental healthcare: a systematic review Qual. Saf. Health Care, December 1, 2006; 15(6): 409 - 413. [Abstract] [Full Text] [PDF]