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Bevan Exemplar Cohort 8 Projects

Improving patient safety and reducing medicines waste through cluster based post hospital discharge medication reconciliation

Ivana Wong

Cardiff and Vale University Health Board

Since March 2020 the Cluster Pharmacists at Cardiff South West Cluster have been core members of a Cluster integrated care hub. We support patients with medicines reconciliation undertaking a medicines reconciliation process for all patients discharged from hospital (approximately 550 per month) since September 2020.  This has allowed a rapid, safe and effective update of medications, improving the quality of care, freeing up time of primary care teams to work prudently.

Through this work, we have identified a number of errors of commission and omission and mitigated potential patient safety issues.  Issues relating to medication communication in Discharge Advice Letters (DALs) on discharge from hospital cause confusion for patients, increased workload across primary and secondary care. There is also increase risk of harm to patients and the potential for readmission to hospital. We would like to work with the UHB to improve the process across the interface.

There are no other clusters yet operating this model in Cardiff and Vale UHB leading to inequity of care across the area. We will spread the model to other clusters in the locality and collect data over a larger pool to help inform changes to the discharge summary process at UHB level.


To improve the quality and safety of the transition of care between secondary and primary care.


  • To spread our model of cluster pharmacist led medicines reconciliation to 2 other clusters in the next year.
  • Use this spread to collect additional data on the errors occurring around DALs.
  • Inform improvement work within the UHB to improve the reliability and safety of producing DALs.

Anticipated outcomes:

The risk to patients being discharged form hospital has been mitigated in Cardiff SW Cluster through the interventions implemented by the cluster pharmacists, including calling wards, liaising with community pharmacy, families, carers and GP surgeries. This has been reflected in a lower readmission rate than other clusters in the UHB area.

Other clusters are not yet offering this service and thus there is a huge risk pool in the community arising from these omissions with practices either carrying out this work themselves or the work not being done at all.

The anticipated outcomes will be:

  • Increased number of patients having a pharmacist led medicines reconciliation
  • Reduced amount of GP time being spent on administrative work
  • Reduced readmissions.
  • Reduced harm to patients
  • Improved DALs process across the UHB area
  • Cost savings through more prudent use of workforce

Improved consistency of discharge advice letter completion and delivery to clusters/practices would improve patient safety and reduce workload in primary care and acute wards.