Community Pharmacy Services at the Primary-Secondary Care Interface
B. Duggan and S.A. Ryder
University of Dublin, Trinity College, School of Pharmacy and Pharmaceutical Sciences, Dublin 2.
Published abstract available at: http:/ / dx.doi.org/ 10.1007/ s11096-011-9602-2 International J ournal of Clinical Pharmacy 2012 Feb; 34(1):211-2. Email: email@example.com
Drug-related problems and medication errors, many preventable, are known to make
a significant contribution to morbidity and mortality. The point of transfer between
primary and secondary care provides opportunities for medication errors to arise,
especially in the absence of structured transfer protocols.1The 2008 government
report Building a Culture of Patient Safety2acknowledges the movement of patients
from one care setting to another and the need for integration:
“A great deal of modern healthcare is multi-disciplinary in nature and patients
frequently have to move between different healthcare providers in accessing
care. Providing patient-centred, seamless care requires robust integration
mechanisms and strong governance arrangements which ensure that patients
receive safe and high quality care where different aspects of their care are
provided across different providers”provided across different providers.
There has been limited national and international research into mechanisms to
facilitate seamless transfer across the primary-secondary care interface, with studies
primarily focused on hospital based services. Little attention has been paid to the
potential contribution of community pharmacy based services.3-6The purpose of this
research was therefore to examine current levels of communication between
community pharmacies and hospitals, to investigate the extent and nature of errors
that arise on discharge, and to explore pharmacists’ perceptions of current
procedures, with a view to future development of structured seamless care protocols.
The response rates for the community pharmacist and hospital pharmacist surveys
were 49% and 60% respectively.
Hospital pharmacists reported ongoing difficulties in attempting to obtain an accurate
patient medication history on admission, with 76% of respondents stating that they
regularly, often or always encountered these difficulties. This is reflected in their
overall satisfaction with the admission process. The majority of hospital and
community pharmacists were also dissatisfied with the discharge process (Figure 3).
Figure 3: Pharmacists’ level of satisfaction with admission and discharge processes
very dissatisfied very dissatisfieddissatisfieddissatisfiedneutral neutralsatisfied satisfiedvery satisfiedvery satisfied
A log book of all communications between a community pharmacy and hospitals were
maintained for a period of 365 working days. A retrospective review of all
prescriptions dispensed under the hospital emergency scheme in the same community
pharmacy over the course of one year was also carried out. New discharge and post-
discharge prescriptions were also compared as they were presented in the community
pharmacy. The data were coded and analysed in SPSS v. 16. Standard statistical
parameters were calculated and statistically significant relationships were determined
using ANOVA and the χ2-test where appropriate, taking p<0.05 to be significant.
(a) Hospital pharmacists’ satisfaction
(b) Hospital pharmacists’ satisfaction
(c) Community pharmacists’
satisfaction with discharge
The opinions of community pharmacists and hospital pharmacists were sought in
relation to the current procedures in place for the admission and discharge of
patients, with particular reference to drug therapy. Self-administered anonymous
postal questionnaires were sent to one third of the community pharmacies
(geographically stratified) and to all hospitals listed as part of the HSE national(geographically stratified) and to all hospitals listed as part of the HSE national
hospitals office group and 19 additional hospitals registered with the PSI.
At present there is little communication across the interface at the time of discharge,
with 11% of community pharmacists reporting that they had never been contacted by
a hospital to inform them of an imminent discharge of a patient, and a further 80%
stating that they were only contacted occasionally. Community and hospital
pharmacists identified similar reasons for communication at discharge currently.
Figure 4: Reasons for contact between hospital and community pharmacy at time of
Identified by hospital pharmacists
Identified by community pharmacists
RESULTS AND DISCUSSION
Communication log book
A total of 216 communications between the community pharmacy and hospitals were
recorded during the study period. This represents an average of 0.59 communications
a day or one communication for approximately every 15 hrs the pharmacy was open.
In absolute terms there appeared to be little difference between the number of
communications dailyfrom Monday to Thursday,
communications occurring on Friday. However, when this was compared to the
number of prescriptions originating from hospitals that were dispensed on the variousnumber of prescriptions originating from hospitals that were dispensed on the various
days of the week, far more communications were recorded on Mondays and Fridays
than might have been expected, with a much lower level being recorded for Tuesdays
and Saturdays. There was, therefore, a significant difference between the days on
which communication occurred (p=0.01, χ2-test). This may be explained by weekend
discharges with the need for additional follow-up after the weekend if prescribers
were uncontactable on Saturday, and Monday admissions.
with a higher number of
% of respondents
High Tech medicine prescribed
Medicine that is difficult to source
Particular patient groups
Particular time of day
No special circumstances
In view of the level of dissatisfaction with current admission and discharge
procedures, it is not surprising that 98% of community pharmacists and 97% of
hospital pharmacists believed introduction of a structured seamless care programme
linking hospitals, general practitioners and community pharmacists to be either
important or very important 86% of community pharmacists and 74% of hospitalimportant or very important. 86% of community pharmacists and 74% of hospital
pharmacists were in favour of hospital pharmacies having a designated pharmacist
with responsibility for facilitating seamless patient care at discharge. The lower level
of enthusiasm among hospital pharmacists may stem from concerns about the
logistics and workload impact of such an initiative.
The reason for each communication and the outcome were also recorded (Figure 1).
In 81% of cases, communication was sufficient to resolve the issue.
Figure 1: Communication between hospitals and the pharmacy
The most popular pieces of information that community pharmacists would like
hospital staff to communicate to a patient’s nominated community pharmacy on
discharge (those identified by >50% of respondents) are displayed in Table 1. The
preferred means of communication were fax (30%), a letter carried by the patient
(28%) and telephone (26%). E-mail (9%) and post (7%) were far less popular,
probably due to concerns about security and timely receipt of the information.
(a) Reasons for communication (a) Reasons for communication(b) Outcome of communication (b) Outcome of communication
Table 1: Information desired by a majority of community pharmacists at discharge
New medicines and reasons for introduction
Discontinued medicines and reasons for cessation
Discharge prescription, if any
Intended duration of therapy of prescribed medicines
Adverse drug reactions in hospital
Dressings in use at time of discharge
Use of drugs outside terms of product license
Potential drug-related problems/interactions
% of respondents
0510 15 202530
Check patient's history
Obtain information about med
Confirm stock of med
Alert to imminent discharge
Confirm discontinued med
Confirm new med
To get info and return call
Admin info provided
Current med confirmed
Dr not available at the time
New med confirmed
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The involvement of community pharmacists in seamless care is inconsistent at
present, and both community and hospital pharmacists are dissatisfied with current
arrangements. The findings of this study will feed into a protocol for a pilot
community pharmacy-based seamless care programme.
Comparison of new discharge and post-discharge prescriptions
436 prescriptions were dispensed in total accounting for 990 items. 42% of the
items were dispensed in full, therefore no further prescription was required from the
patient’s GP. 445 items required a follow up prescription to be issued. When the GP
prescriptions were presented in the pharmacy it was found that for 121 items (27%)
the follow up was incorrect. This is comparable to the error frequency found by
hospital pharmacists in medication reconciliation at admission.4
Figure 2: Nature of errors on follow up prescriptions
% of communications
% of communications
010 203040 5060
Incorrect duration of therapy
Incorrect item prescribed
Drug inappropriately continued
New therapy not continued
Incorrect dose prescribed
% of errors
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