Recurring concern
Unreliable communication of discharge medication information to care staff
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Request correctionFirst reported 20 Aug 2013•Latest report 4 Mar 2024
What this concern includes
Includes failures in the discharge process to record, communicate, transfer or confirm receipt of patient-specific medication information needed by staff or services responsible for medication administration, prescribing, monitoring or follow-up after discharge.
Not included
- Excludes failures to supply, dispense or physically provide the correct medication at discharge when medication information communication is not deficient.
- Excludes general discharge summaries, follow-up arrangements or clinical information unless the asserted unsafe condition specifically concerns discharge medication information.
- Excludes medication prescribing, reconciliation, administration or monitoring failures occurring after accurate discharge medication information has been communicated.
- Excludes generic record-keeping, communication or staffing deficiencies without a material discharge-medication-information context.
- Reports
- 8
- Individual concerns
- 8
- Date range
- 2013–2024
- Stated actions
- 8
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to document and communicate discharge medication recommendations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Record when a reduced medication quantity should be prescribed because of self-harm or overdose risk.
Stated by Dartford and Gravesham NHS Trust and Kent and Medway Mental Health NHS Trust -
Action
State in discharge notifications when medication has been reduced and record the reason.
Stated by Dartford and Gravesham NHS Trust and Kent and Medway Mental Health NHS Trust
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Concerns raised1
Failure to flag potential medication-use risks to staff before discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Review the electronic health record for proportionate additional safety measures affecting discharge medication processes.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Introduce a coded limited-supply question that triggers prominent alerts and directs doctors and pharmacists to review the medication history before discharge prescribing or dispensing.
Stated by Milton Keynes University Hospital NHS Foundation Trust
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Concerns raised1
Failure to provide original prescribers with information about suspended or stopped medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Fund EPMA implementation in an additional 25 NHS trusts.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Individual trusts remain responsible for discharge summaries and transferring medication information after discharge.
Stated by NHS England
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Position
Existing legal and professional duties provide a sufficient framework for information sharing, so further data-sharing requirements are unnecessary.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to communicate the Discharge Medication Summary to relevant parties
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to communicate with community GPs before discharge about ongoing melatonin prescribing
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Review the case with the practice to identify further learning.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised1
Failure to reliably notify GPs of discharge medication types and quantities
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Plan the technical changes required to notify GPs electronically about prescribed discharge medication.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Failure to communicate the discharge medication safety arrangement to the consultant psychiatrist
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide discharging staff with clear information about medication supplied at discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026