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“The aim of DMS is to make sure that patients understand their new medication and how to use it, and to better communicate changes to the medication with their GP and pharmacist”

When a patient is discharged from hospital, changes to their medication can result in an increased risk of harm caused by their drugs, sometimes leading to readmission. An NHS service in England aims to avoid that.


Wales, Scotland and Northern Ireland

Discharge Medicines Review have been running in Wales since 2012. Funded by NHS Wales, the service is part of the Community Pharmacy Wales Good Health – Lechyd Da initiative. In Scotland there is not a national service, but some local NHS Boards run schemes. There is no equivalent service in Northern Ireland.


The NHS Discharge Medicines Service (DMS) ensures better communication between healthcare providers of any changes made to a patient’s medication when they leave hospital, reducing incidences of avoidable harm. DMS sees healthcare professionals in primary and secondary care working together to support patients with their medicines.


When people are discharged from hospital, often there are changes to their medicines. An estimated 60% of patients have three or more changes made to their medicines during a hospital stay. This can result in confusion about which ones they should be taking after discharge. Therefore it is important that patients fully understand their medicines once they return home.


The aim of DMS is to make sure that patients understand their new medication and how to use it, and to better communicate changes to the medication with their GP and pharmacist.

Patients may be referred to the scheme by their NHS Trust if they’ve been in hospital and have been discharged with new medicines and it is deemed they will benefit from extra help and guidance with the drugs. Once a patient consents to a referral, the NHS Trust will send it to the pharmacy via a secure electronic system.

After receiving the electronic referral, the pharmacy will check clinical information and actions contained within the referral which need to be undertaken.

What they will be checking for will be any changes such as to quantity, dosage or frequency of a prescribed medicine. They will compare the medicines the patient has been discharged with and those they were taking at admission. Any issues identified will be raised with the NHS Trust or the patient’s general practice.

The pharmacy also will check any prescriptions for the patient that were previously ordered in the dispensing process or are awaiting collection to see that they are still appropriate.

A confidential discussion will also take place between the patient and the pharmacist about the medication to ensure they are clear about how the drugs should be taken. The pharmacist will check that the patient understands their medicines regime and if they have any issues with following it, for example, some patients may have memory problems.

The consultation should take place in an appropriate place at the pharmacy but remote consultations will also be available if one is requested. This discussion may also include the patient’s carer if they have one.

Data shows that patients who see their community pharmacist after they have been in hospital are less likely to be readmitted and will experience a shorter stay if they are.

‘High-risk’ patients include those prescribed anticoagulants, antiepileptics, opioids and lithium and a number of other medications.

DMS also targets patients who are prescribed a new medicine while in hospital, those who are “confused about their medicines on admission”, anyone with a learning disability and those who have help at home to take their medications, among other groups.



There is plenty of evidence that discharge from hospital can be associated with an increased risk of avoidable medication-related harm:

  • 90 per cent of elderly patients will be discharged with a change to the medication that they were admitted to hospital on
  • 20% of patients have been reported to experience adverse events within three weeks of discharge, 60% of which could have been managed or avoided