Medicines safety

Finding solutions to increase referrals to the Discharge Medicines Service

Effective communication between healthcare professionals within the secondary and primary care sectors is the key to ensuring a safe transition of patient-centred care on discharge. The NHS Discharge Medicines Service (DMS) is an essential service that has been established to secure a superior line of communication between the different care sectors, delivering a more integrated and safer approach to medicines. 

What is the Discharge Medicines Service?

The DMS aims to:

  • Optimise medication use and facilitate shared decision-making
  • Reduce harm from medications at the point of transfers of care
  • Improve patient understanding of their medications and how to take them
  • Reduce hospital readmissions
  • Support and build open lines of communication to allow for effective team working across hospital, community, and PCN pharmacy teams.

There are three stages to the DMS service, where it is expected that all patients referred will receive all three stages, although this may be provided sequentially or in parallel depending on the individual patient.

Stage 1: A discharge referral is received by pharmacy

  • Check clinical information and actions within the referral
  • Compare the medications the patient has been discharged on and those being taken pre-admission. Raise any issues as appropriate.
  • Check any prescriptions previously ordered or awaiting collection to see if they are still appropriate.

Timescale: As soon as possible, but within 72 hours of receipt, excluding when pharmacy is not open.

Stage 2: The first prescription is received by the pharmacy following discharge (may not be a repeat prescription) 

  • Ensure medications prescribed post-discharge take account of the appropriate changes made during the hospital admission. The pharmacy team should resolve any discrepancies with the GP practice utilising communication channels.

Timescale: When the first post-discharge prescription is received (usually one to four weeks post-discharge).

Stage 3: Check the patients’ understanding of their medicine’s regimen.

A confidential discussion via a shared decision making approach with the patient or carer to check understanding of medication, what they should be taking or using, when they should be taken or used, and any other relevant advice. When necessary, offer to dispose of any medications that are no longer required to avoid potential confusion and prevent an adverse event.

Timescale: When the first post-discharge prescription is received.

The challenge 

A current challenge for secondary care sectors is the rate of re-admissions into hospital within 30 days of discharge. Approximately 20 percent of hospital readmissions are medication-related, of which 70 percent are preventable. In older adults, the risk of readmission is higher because of polypharmacy becoming increasingly common. This puts patients at higher risk of medication-related harm. It is to be noted, patients are most vulnerable to problems arising with their medication in the period following a hospital discharge due to medication changes occurring, and poor information transfer between secondary and primary care settings. One study demonstrated 37 percent (n=413) of patients experienced medication related harm, representing 556 events per 1,000 participants over an eight-week timeframe. Of this, 81 percent (n=336) were serious and 52 percent (n=214) were identified as potentially preventable. Over 70 percent of these events were attributed to medications prescribed at the point of hospital discharge. The medications associated with the highest risk of causing harm were opiates, antibiotics, and benzodiazepines. The estimated overall annual cost is £396 million with £243 million thought to be preventable.

Policy drivers for the Discharge Medicines Service

DMS was proposed as a solution to address some of these issues that occur upon discharge from secondary care. DMS allows the sharing of decisions made in the hospital around an individual’s prescribed medicines. This transfer of information is made in close collaboration with healthcare professionals in the two different sectors, and the patient and/or their family. This process supports implementation of one of the recommendations from the NICE guideline Medicine optimisation: the safe and effective use of medicines to enable the best possible outcomes

“Medicines-related communication systems should be in place when patients move from one care setting to another, and medicines reconciliation processes should be in place for all persons discharged from a hospital or another care setting back into primary care, and the act of reconciling the medicines should happen within a week of the patient being discharged, the DMS is a pivotal service provision.

In view of the benefits realisation of DMS, the Commissioning for Quality and Innovation (CQUIN) target for hospitals has been agreed to encourage each Trust to make referrals via the DMS service. The outcome of this being that patients referred via DMS are less likely to be readmitted (5.8 vs 16 percent at 30 days). If patients are unfortunately admitted, evidence suggests that they will spend fewer days in hospital.

Understanding our baseline

Within our Trust we noticed that the number of DMS referrals completed from November 2022 to January 2023 were significantly below the set CQUIN target, remaining in single figures. The biggest barrier previously reported was the Pharm Outcomes portal not being integrated with our electronic systems. This meant many referrals each month were not even surpassing single digits.

Acknowledging that this integration was pivotal in achieving the CQUIN target, we worked with the Information Communications and Technology (ICT) department and our system partners to successfully automate the referral directly from our discharge letter. However, these referrals were still a third under our target. 

To gain an understanding of the barriers to making DMS referrals we completed an audit of reasons why referrals were not made. The audit was completed over one week between Monday 6 February and-Friday 10 February 2023 to assess the barriers. This was to aid implementing extra support and resources within the department to increase the number of patients benefiting from this vital service. 

Undertaking the audit and the results 

During the week of the audit a total of 572 discharges were processed by the pharmacy department; however, only 70 of these had a DMS referral processed.

From the total discharges that were processed, between 22.5 and 44.3 percent of discharges per day (which accounts for 146 discharges for the week) were ineligible for a DMS referral due to one of the following reasons: 

  • Patient was unable to consent due to residing in a care home or had dementia
  • No changes were made to regular medication
  • Patient had been discharged on a short-term course of treatment i.e., laxatives, analgesia, and antibiotics
  • Patient did not fit the referral criteria i.e., chemotherapy patient, end of life discharge, use of a syringe driver, and used of GP pharmacy dispensary
  • Patient did not have a nominated pharmacy on SCR
  • Language barrier and consent could not be obtained
  • Patient was being transferred to a rehabilitation centre.

There were still 356 discharges remaining that on the surface seemed to be missed opportunities for referral and potentially prevention of medication related harm. When looking further into the rationale for why the team had not made a referral for a patient, we identified areas for improvement that would enable a higher number of DMS referrals. These were summarised into themes:

  • Discharge letter screened away from the ward or drug chart where the DMS consent is recorded
  • Patient was not present on the ward at the point of discharge
  • An addendum discharge letter was completed for the patient
  • The patient refused to have a DMS referral completed
  • Other, i.e., pharmacist did not have time to gain consent, patient was asleep, COVID positive patient.

Improving this would not only improve the care to our patients when transitioning from secondary to primary care, but also release efficiencies within the system.

What did this mean for our Trust? 

From collecting this data, we were able to identify areas that could be improved. One of the reasons identified was the lack of communication from the pharmacy team in discussing the benefits of the DMS service when consenting a patient. To support this, we framed this conversation as the ‘Helping Hand Model’. The Helping Hand Model created a visual aid for the pharmacy team to encompass and reinforce the purpose of completing a DMS referral to patients. As the pharmacy team, we wanted to be the ‘Helping Hand’ that guides and provides reassurance to the patient through their inpatient journey in relation to medication safety and optimisation.

We guide the patient over the bridge from secondary to primary care, ensuring the patient has a seamless transition of care, knowing they have the support mechanisms in place on discharge. The purpose of this model was to highlight the importance of making every moment count throughout their journey as an inpatient. This ensures we are communicating with the patient from the first encounter on admission, when the drug history is taken, all the way through to when the patient is discharged.

Documenting and communicating the consent for DMS seemed to play a big part in the lack of referrals. Acknowledging that consent may not always be possible for patients (if they are too unwell or confused, for example) and therefore encouraged teams to document this as an outstanding task that could be picked up later. 

Actions to support improvement 

1. Refresher training and raise awareness about impact

The results were presented to the department, which enabled the team to view and reflect on missed opportunities and how these would translate to savings in terms of reduced length of stay and admission avoidance. We also informed the team about all the steps in the DMS process and how patients could be referred for some or all the steps to support the transition of care from secondary to primary care.

2. Standardise documentation and streamline process

We emphasised our new systems of capturing the DMS consent at the point of admission. In addition, we highlighted that opiates and antibiotics were within the medication categories associated with the highest risk of causing harm, and therefore particular emphasis on consenting these patients needed to be made.

3. Walk the floor and just ask

One of our key points as a department is that when something is not working we encourage open conversations, being curious and asking. This has enabled us to discuss and discover. In this case we had a team that undertook ward visits to proactively discuss DMS and the impact, and whether people understood the value that DMS bought to their patients. This allowed open conversations and signposting to further support if needed.

4. A visual target 

To further support and encourage colleagues, a visual aid on our huddle boards was created. This was to show the total number of DMS referrals completed each week, and how we were progressing towards our target. 

Post-audit and intervention

Since the audit was conducted and the above measures were implemented, the total number of DMS referrals completed has grown significantly, putting us 50 percent above our target. Whilst the measures taken were not complicated or large changes in our processes, they still delivered impact and change. We are now consistently referring patients beyond our target, and this is encouraging to us as a team; we know that we are improving the care being provided to our patients beyond the point that they leave our care. 


The achievements of this project were attained through the collaborative efforts of various members within our team. Hardeep Bagga who had the vision and worked across the system to get this project off the ground. Phillippa Colenutt, James Morris, Simone Gardner and Rebecca Wong who diligently tested and provided invaluable support during the implementation of our new workflows. Lastly, our commendable systemwide ICT team deserves special recognition for their indispensable support in facilitating the realisation of these achievements alongside us.

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.


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