Poor communication of information at transition points is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in hospital.  Practices should have a process for medicines reconciliation before admission and after discharge from secondary care and a means of identifying patients at high risk of medicines related adverse events.


Please see the following two NHS Somerset guidance documents:           

Provision of patient information on admissions from Primary Care

Reconciliation of patient information post-discharge


From Primary to Secondary Care   From Secondary to Primary care
  • Complete patient details
  • Complete patient details
  • The presenting condition plus co-morbidities
  • The diagnosis of the presenting condition plus co-morbidities
  • A list of all the medicines currently prescribed for the patient with indications
  • Dose, frequency and route of all the medicines listed
  • Any OTC medicines or supplements the patient takes
  • Medicines stopped and started, with reasons
  • Dose, frequency and route of all the medicines listed
  • Length of courses where appropriate
  • An indication of any medicines that are not intended to be continued (eg.acute prescriptions)
  • Details of increasing or decreasing regimes
  • Known allergies
  • Known allergies
  • Known previous side effects
Suggestions for Drug Monitoring in Adults in Primary CareThe monitoring parameters cited in the formulary are derived from a range of guidelines, reference sources, and expert opinion and must therefore be considered suggestions only. Adherence to them will not ensure a successful outcome in every case. The ultimate judgement regarding a particular clinical result must be made by the doctor in light of the clinical data presented by the patient and the diagnostic and treatment options available. Please see the Suggestions for Drug Monitoring in Adults in Primary Care document.