The incidence and severity of errors in pharmacist-written discharge medication orders
The incidence and severity of errors in pharmacist-written discharge medication orders
Raliat Onatade 0 1 2 3 4 5
Sara Sawieres 0 1 2 3 4 5
Alexandra Veck 0 1 2 3 4 5
Lindsay Smith 0 1 2 3 4 5
Shivani Gore 0 1 2 3 4 5
Sumiah Al-Azeib 0 1 2 3 4 5
0 Pharmacy Department, Barts Health NHS Trust , London E1 2ES , UK
1 Pharmaceutical Sciences Clinical Academic Group, King's Health Partners , London , UK
2 Institute of Pharmaceutical Sciences, King's College London , London , UK
3 Pharmacy Department, Royal Brompton and Harefield NHS Foundation Trust , London , UK
4 Pharmacy Department, Western Sussex Hospitals NHS Foundation Trust , Chichester , UK
5 Pharmacy Department, King's College Hospital NHS Foundation Trust , London , UK
Background Errors in discharge prescriptions are problematic. When hospital pharmacists write discharge prescriptions improvements are seen in the quality and efficiency of discharge. There is limited information on the incidence of errors in pharmacists' medication orders. Objective To investigate the extent and clinical significance of errors in pharmacist-written discharge medication orders. Setting 1000-bed teaching hospital in London, UK. Method Pharmacists in this London hospital routinely write discharge medication orders as part of the clinical pharmacy service. Convenient days, based on researcher availability, between October 2013 and January 2014 were selected. Preregistration pharmacists reviewed all discharge medication orders written by pharmacists on these days and identified discrepancies between the medication history, inpatient chart, patient records and discharge summary. A senior clinical pharmacist confirmed the presence of an error. Each error was assigned a potential clinical significance rating (based on the NCCMERP scale) by a physician and an independent senior clinical pharmacist, working separately. Main outcome measure Incidence of errors in pharmacistwritten discharge medication orders. Results 509 prescriptions, written by 51 pharmacists, containing 4258 discharge medication orders were assessed (8.4 orders per prescription). Ten prescriptions (2%), contained a total of ten erroneous orders (order error rate-0.2%). The pharmacist considered that one error had the potential to cause temporary harm (0.02% of all orders). The physician did not rate any of the errors with the potential to cause harm. Conclusion The incidence of errors in pharmacists' discharge medication orders was low. The quality, safety and policy implications of pharmacists routinely writing discharge medication orders should be further explored.
Hospital pharmacy; Medication; Medication errors; Medication safety; Patient discharge; Pharmacist; Prescribing; Quality; United Kingdom
Impact on practice
Pharmacists can safely write discharge medication
orders as part of a routine clinical pharmacy service.
Larger studies are needed to research the clinical
significance of pharmacists’ medication order errors.
Pharmacists writing discharge medication orders may
offer opportunities to improve the quality and safety of
patient care transitions.
Errors associated with hospital discharge prescriptions (To
Take Aways, TTAs) are problematic and well documented
in the UK [1–5]. For example, results from the EQUIP
study of prescribing errors in twenty UK hospitals detected
errors in 6.3% of doctors’ discharge medication orders
(individual items in a prescription) . In a study of
prescribing errors in three UK mental health hospitals, 6.5% of
discharge medication orders were associated with an error
Accurate discharge medication orders are essential to
ensure patient safety during transitions of care [2, 5].
Discrepancies can have important clinical consequences.
Subsequent caregivers may also base actions and decisions
on the information contained in discharge prescriptions,
leading to inappropriate treatment if this information is
inaccurate [2, 5].
Pharmacists are often cited as an essential defence in
preventing prescribing mistakes reaching the patient
[1, 3, 5–7] by detecting and correcting errors before
medication administration. In 2003, suitably trained
pharmacists were given the rights to prescribe in accordance with
pre-agreed, condition-specific treatment plans. In 2006, this
was extended and independent prescribing rights were
granted, on completion of additional training [8, 9].
Nonprescribing pharmacists writing discharge medication
orders instead of physicians has previously been reported,
with noted improvements in quality and efficiency [10–13].
A North American study evaluating a pilot programme
comparing physician- and pharmacist-written discharge
medication prescriptions, found that pharmacists entered
discharge medication orders more accurately than
physicians. Pharmacists reviewed the physician-entered orders,
and physicians reviewed the pharmacists’ orders from the
intervention group. If a change was required to either the
dose or frequency, an order was deemed inaccurate.
Ninety-six per cent of pharmacists’ orders were accurate
compared to 56% of physicians’ orders . Although the
authors emphasise that statistical analyses were not
conducted, post hoc calculations indicate a significant
difference between the two groups (95% CI for the difference in
proportions = 33–46%, Chi Square test p \ 0.0001). A
study carried out in the UK compared pharmacist- and
doctor-written discharge prescriptions on a surgical ward.
Pharmacist-written prescriptions contained considerably
fewer errors, omissions and unclear information in
comparison to those written by doctors. All prescriptions were
checked by the other profession, and additionally by
clinical dispensary pharmacists. The number of dispensary
pharmacists’ interventions increased 10-fold when
checking doctor-written prescriptions. Additionally, doctors
made 10 minor alterations to the pharmacists’
prescriptions, while pharmacists had to clarify the doctors’
prescriptions on 52 occasions . Whilst demonstrating the
value of pharmacists ordering discharge medication, these
studies have only evaluated pilot programmes, on one or
two hospital wards within an organisation. They included
relatively few prescriptions or patients and the clinical
significance of pharmacist errors was not evaluated.
Aim of the study
The aim of this study was to quantify, describe and
determine the clinical relevance of errors in
pharmacistwritten discharge medication orders in a large teaching
hospital where pharmacists writing discharge medication
orders is a routine clinical pharmacy service.
The study was approved by the local Research and Audit
Committee as a retrospective service evaluation. Ethics
approval was not required, in accordance with National
Health Service Research Authority Guidelines.
This was a retrospective, observational study.
Prescribing errors were defined according to Dean et al.
. A discharge prescription (TTA or PTTA if written by
a pharmacist) is the list of medicines that a patient should
be taking on discharge. A discharge medication order is an
individual item within the list of medicines.
Setting and participants
The study was undertaken in a 1000-bed teaching hospital
in London, UK. Around 2600–3000 TTAs are processed
every month by the hospital pharmacy. Pharmacists
generate approximately 24,000 discharge medication orders
every month, constituting 75–80% of all discharge
medication orders. Electronic prescribing and medication
administration (EPMA) is implemented across the hospital
and discharge medication is ordered on the electronic
system. There is no computerised decision support in the
EPMA system. Pharmacists review all medication orders
and discuss and resolve potential and actual errors with
Once informed of a pending discharge, the pharmacist
takes responsibility for writing the discharge medication
orders. Medication for discharge is always supplied by the
hospital pharmacy. The process of writing a list of
discharge medication (pharmacist-written TTA, PTTA)
using EPMA involves reordering the required inpatient
medication as discharge medication orders. The pharmacist
also consults with the patient, nurse and physician and
checks the documented medication history. Pre-admission
medication withheld during admission is restarted if
appropriate and new medication may be started. The
pharmacist sends a printed copy of the PTTA to the
dispensary for medication to be supplied. Not all medication
requires dispensing, as the patient may have sufficient
supplies at home. However, all should be listed on the
PTTA, for clarity. The dispensed medication is sent to the
ward, and the printed list is retained in pharmacy. The
pharmacists are writing discharge medication orders but
they are not prescribing. At any point during this process,
the patient’s physician checks the discharge medication
orders, and completes, prints and signs the discharge
notification (a larger document incorporating the
pharmacist’s medication orders plus clinical and other treatment
details), for the patient to take home with their medication.
If any changes to the medication orders are required before
discharge, the physician makes the changes, or the
pharmacist will be notified by the physician or nurse to amend
the PTTA. If the pharmacist makes the amendments, the
PTTA will not be rechecked by another pharmacist. Any
errors corrected at this stage would not have been identified
as part of this study. An electronic copy of the discharge
notification (eDN) is also sent to the patient’s general
A sample size calculation was performed, using
inhouse exploratory data, collected prior to implementation
of EPMA (i.e. when paper charts were in use). This
indicated that 32% of physician-written TTAs contained at
least one erroneous discharge medication order and 9% of
all discharge medication orders were erroneous (9% order
error rate). This determined that 500 PTTAs would be
sufficient to observe an error rate similar to, or smaller than
that found in physician-written TTAs. Stratified sampling
was applied to ensure proportionate representation of wards
or units belonging to each major clinical specialty. As a
pharmacist will consistently work on just one or two wards,
this also ensured orders made by a wide range of
pharmacists were captured.
On convenient (when researchers were available) days
between October 2013 and January 2014, researchers (AV,
LS and SG—all pre-registration pharmacists who do not
write PTTAs) reviewed all PTTAs dispensed by pharmacy
one week earlier. The days chosen varied between Monday
and Saturday. Data collection continued until the target
sample sizes for the total number of PTTAs and the
required number per specialty were reached. The printed
PTTAs retained in the dispensary contain the
pharmacistwritten discharge medication orders, prior to the physician
check. AV, LS and SG compared the PTTAs to three
sources to detect errors—medication history, the inpatient
drug chart and the eDN. The eDN is an unalterable
document, authorised by the physician to be saved
electronically to the patient record, after checking the medication
orders and completing the clinical details. On both the
PTTA and the eDN, the discharge medication orders have
the name of the ordering professional listed alongside the
order and the date any modifications were made. This made
it possible to identify changes made by physicians after the
pharmacist had sent the printed PTTA to the dispensary. If
differences or discrepancies (including the addition or
omission of a medication, duplication of therapy,
differences in formulations, doses or dose frequencies) between
the medication orders on the PTTA and any of the other
sources were identified, all documentation was passed to a
senior clinical pharmacist (SS or SA) who reviewed the
patient record and used clinical judgment to decide if an
error had occurred. SS would be given any PTTAs written
by SA, and vice versa. Where necessary, the pharmacist
who wrote the PTTA was asked to clarify a discrepancy. If
an error was identified, the research team took appropriate
remedial action, to ensure patient safety. Exclusions were
any PTTAs which were checked by a second pharmacist
before being dispensed (this would be the case when a
pharmacist was being trained to write discharge medication
orders), and any for which the comparative sources were
missing or inaccessible.
Errors were categorised according to the type of
prescription error (omission, commission/addition,
duplication, administration frequency, dosage form, route) derived
from those used in similar studies [1, 15, 16]. All errors
were also independently rated for their potential clinical
impact by one senior physician and one senior clinical
pharmacist (not otherwise associated with the study). The
raters were given descriptions of the errors (Table 2) and
asked to use their clinical and professional judgment to
categorise each error according to a validated adaptation of
the National Coordinating Council for Medication Error
Prevention (NCCMERP) index and descriptors for
potential harm [17, 18]. Consensus between the two raters was
Data were organised with Microsoft Excel 2011. Statistical
analyses, including frequencies and proportions, were
performed using IBM SPSS for Macintosh, Version 21.
Data collection took place over twenty-two days. A total of
509 PTTAs (509 patients), with 4258 discharge medication
orders made by 51 pharmacists, were assessed—a mean of
8.4 orders per PTTA. This equated to approximately five
days of PTTA workload. The breakdown of specialties is in
Table 1. Overall, 10 errors in 10 PTTAs were detected,
giving a 2% (10/509, 95% CI 0.8–3.2%) PTTA error rate.
The percentage of orders with an error (order error rate)
was 0.2% (10/4258, 95% CI 0.1–0.3%).
Table 2 gives details of each error. Overall agreement
for harm versus no harm between the physician and
pharmacist was 90%. As there were only ten errors, agreement
was not corrected for chance. The physician did not rate
any errors with the potential to cause harm. The pharmacist
rated one error with the potential to cause temporary harm.
This was an omission of a diabetic patient’s regular
antihypoglycaemic medication from the PTTA. The patient
had been using these before admission. This equated to
0.02% (1/4258) of pharmacist discharge medication orders
potentially causing harm.
This is the first study to quantify error rates in pharmacists’
discharge medication orders, where this is a routinely
provided clinical pharmacy service. It is observational
only, with no comparisons with physician error rates before
pharmacists started writing the orders. The introduction of
the pharmacy service coincided with EPMA
Number of Percentage of
PTTAs total (%)
Ward or unit specialty
implementation. Thus any attempt to draw conclusions
from a direct before-and-after comparison of
pharmacistand physician-errors would be inappropriate.
The proportion of PTTAs containing an error was 2%,
with 0.2% of all orders being erroneous. Franklin and
colleagues in their study of doctors’ prescribing errors on
UK medical and surgical wards, found that 9% of discharge
medication orders from medical admissions and surgical
wards were erroneous . In a study of prescribing errors
in nine hospitals in North-West England, Seden et al. 
reported that 34.5% of TTAs written by a doctor contained
at least one prescribing error. Studies of errors in
pharmacists’ medication orders have not been widely reported.
Baqir et al.  found an error rate of 0.3% in 1415
pharmacists’ medication orders for hospital inpatients.
There is currently no equivalent information on
pharmacists’ discharge prescriptions with which to compare our
results. Additionally, we assessed pharmacists’ discharge
medication orders in the context of an electronic
prescribing and administration system, whereas the
aforementioned studies used paper-based systems. The
pharmacists’ error rate in this study was lower than that of
physicians, found in a UK study of pharmacists’
interventions in physician-written discharge medication orders
. This study was also in the context of an electronic
prescribing system. Orders were entered for 1038 patients.
At least one error was found in 20.4% of discharge
prescriptions. There were 630 erroneous orders out of a total
of 7920 orders, an order error rate of 8%. Errors were rated
as serious (2.9%), significant (76.3%) and minor (20.8%).
Independent raters found that the few pharmacists’
errors in this study had low clinical importance. These
results and work by other researchers  indicates that
much larger datasets are needed to draw conclusions on the
potential for harm from pharmacist prescribing errors.
The comprehensive nature of this study is a significant
strength. Unlike other work, we assessed prescriptions
written by a wide range of pharmacists, working in all
major clinical specialties. Therefore, a degree of real-world
generalisation to similar hospitals with similar systems is
possible; although electronic prescribing systems with
clinical decision support may potentially further reduce
errors. This study has also added to the emerging evidence
regarding the safety of pharmacist prescribing .
There are some limitations to this work. Workflow
constraints meant that it was not possible to check the
PTTAs immediately after they were written. This reduced
any potential Hawthorne effect (where individuals modify
or improve their work because they are aware they are
being observed). However, corrections requested by
physicians before the PTTA was printed and changes made
by physicians, but not documented, will not have been
An adolescent patient with a history of cystic fibrosis was using prescribed salbutamol inhaler as required, before Physician: C
and during admission. This was not listed as discharge medication. (Specialty—Paediatrics)
A child who had just undergone a liver transplant was using a combination asthma inhaler, before and during
admission, but this was not listed as discharge medication. (Specialty—Paediatrics)
Oral glucose gel 40% and SC/IM glucagon to be used as required for hypoglycaemia were documented on a
child’s pre-admission medication history but not listed as discharge medication. (Specialty—Paediatrics)
A patient, admitted for elective surgery, was taking lansoprazole before admission, but the indication was not
known. During admission, this was changed to intravenous omeprazole, and later oral omeprazole with a stated
indication of stress ulcer prophylaxis. Neither lansoprazole nor omeprazole were ordered as discharge
A patient who had undergone elective liver surgery had been taking regular paracetamol prior to discharge
however, this was not ordered on discharge. (Specialty—Liver)
A patient who had undergone an elective neurosurgical procedure had received a few doses of cyclizine whilst Physician: C
just before discharge and so should have been given a short course on discharge, however they were not.
A patient admitted with a fall, with a past medical history of peripheral vascular disease and type 2 diabetes
mellitus was prescribed Capsaicin cream 1% to be applied to affected areas as required, before and during
admission. This was not ordered as discharge medication. (Specialty—Acute Medicine)
A patient who had undergone elective orthopaedic surgery was taking an average of 40 mg morphine daily when Physician: C
required, plus regular paracetamol and tramadol in the three days prior to admission, but was not discharged
with morphine. (Specialty—Surgery)
Omeprazole 20 mg daily was prescribed for a patient with a history of sickle cell disease, for epigastric pain
during admission but was omitted from the discharge medication (Specialty—Haematology)
Duplicate therapy—1/10 (10%)
A patient was started on trimethoprim at discharge, for a urinary tract infection whilst they were already on
amoxicillin. There was no suggestion of resistance to amoxicillin. (Specialty—Surgery)
Table 2 Frequency of error types and harm categories
Drug omitted—9/10 (90%)
* Key A = Circumstances or events that have the capacity to cause error. C = The error would not cause patient harm OR the error would have
required monitoring or intervention to confirm that it resulted in no harm. D = The error would likely have resulted in temporary harm to the
patient and would have required intervention, initial hospitalization or prolonged hospitalization
detected. Changes made by dispensary staff to orders on
the printed PTTA will also not have been identified.
However, our method for identifying errors in PTTAs
matched the process pharmacists use when checking
physician-written TTAs (i.e. reconciling the TTA with the
medication history, inpatient drug chart and information in
the patient record). Therefore, it is not likely that there
were sufficient undetected errors to have had a significant
effect on the outcome. Due to restricted researcher
availability, data collection occurred on conveniently selected
days. It was felt that ensuring proportionate representation
of all the major clinical specialties was more
methodologically important than randomisation. Risk of bias due
to non-randomisation was minimised by ensuring that only
the researchers knew the data collection days in advance
and by varying the chosen day of the week. Additionally,
the ordering of discharge medication by pharmacists is a
routine service in the organisation and there were no
interruptions to the service during the study. Therefore,
there was little possibility of differences in activity
between data collection and non-data collection days. An
additional bias may have been introduced by excluding
PTTAs for which all three comparative sources could not
The system of pharmacists writing discharge medication
orders, as described above, is not considered prescribing
and the orders have to be checked and signed by a
physician. However, pharmacists have taken over a significant
role which used to be the sole domain of physicians. A full
discussion of the potential negative impact of this type of
role change on physicians’ opportunities to develop
prescribing skills and learn from their own prescribing errors
[20, 21] is outside the scope of this work, and should be the
subject of future research.
The roles pharmacists can play in improving patient
safety at care transitions are well documented [22, 23].
Activities mainly encompass medication reconciliation
[24–26], patient education programmes and post-discharge
follow-up [22, 23, 27–29] and medication reviews
[22, 23, 27]. By demonstrating that pharmacists can safely
write discharge medication orders, the present study has
expanded the evidence-base regarding pharmacist-led
Further studies are needed, including direct comparisons
with medical and other non-medical prescribers, and in
other settings, in order to explore this new role for
pharmacists in improving the quality and safety of care
In this study, the incidence of errors in pharmacist-written
discharge medication orders was 0.2%. The majority of
errors were omitted medications, with one incidence of
duplicated therapy. The clinical relevance of the errors was
minimal although firm conclusions cannot be drawn
because of the low number of errors. There are well-known
safety and quality issues with traditional physician-written
discharge prescriptions, therefore the policy implications of
our findings are important.
Acknowledgements Reena Mehta and Dr. Jonathan Potts assigned
clinical impact ratings to the errors. Professor David Taylor
commented on and edited the manuscript.
Funding This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://crea
tivecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
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