Cluster Pharmacist Discharge Medication Reconciliation Project Summary

Margaret James

Background to the Project

There is a significant risk that patient’s medicines will be unintentionally altered across care providers, which can impact on patient safety 1.

As pharmacy teams in hospital lead on medication-related aspects of hospital discharges, the integration of clinical pharmacists into GP practice enables a similar service undertaking medication reconciliation to be developed in Primary Care, ensuring no unintentional changes are made to patient’s medication and delivering continuity of care on transfer across care settings 2.

Safe systems to manage information and supply of medicines across care providers are central to safe, high quality care 3.

The Project

Undertake medication reconciliation for patients discharged from Medical teams at Withybush General Hospital registered to participating practices in North Pembrokeshire Cluster, in line with Welsh Pharmaceutical Council goal that by 2030 all patients that transfer from one care setting to another, will receive formal review of their medicines from the pharmacy team.

How this will be achieved

Access demographic details of patients registered with participating practices discharged from Medical Teams at WGH via Welsh Clinical Portal.

Clinically review and reconcile medication using remote access to GP practice systems to update repeat prescription and advise on necessary monitoring or follow up as result of changes in therapy. Communicate changes to Community Pharmacy where prescriptions have been issued from General Practice during admission,

Anticipated Benefits

  • Reduce time taken to reconcile discharge medication after electronic discharge advice letter accessible via Welsh Clinical Portal.
  • Reduce variability between staff in practice who undertake medication reconciliation work.
  • Rapid and safe action of information transferred across care settings.
  • Safe and appropriate repeat prescribing following transfer of care, highlighting clinical governance issues such as therapeutic monitoring, communication and counselling for medication changes.
  • Release capacity for clinicians in General Practice.
  • Improve communication of medication changes to Community Pharmacy for patients who require compliance aids to support medication administration.


  1. World Health Organisation Medication safety in transitions of care 2019
  2. Welsh Pharmaceutical Council Pharmacy: Delivering a Healthier Wales. April 2019
  3. Care Quality Commission Guidance about compliance: Essential standards of Quality and Safety March 2010