Implementing a pharmacy-led post‑discharge medicines counselling service for patients prescribed high‑risk medicines

Transitions of care are associated with medicines‑related harm, particularly for patients prescribed high‑risk medicines. NHS England explicitly identifies hospital discharge as a high‑risk moment^​1​, aligning with the World Health Organization’s Global Patient Safety Challenge on Medication Without Harm. National evidence from the Department of Health and Social Care estimates that around 1.8 million medication errors occur annually at transitions of care in England, with approximately 44% occurring at discharge, highlighting the need for structured post‑discharge support^​2​.

In response, the London North West University Healthcare NHS Trust implemented a charity‑funded, fixed‑term post‑discharge medicines counselling service targeting patients prescribed high‑risk medicines. The service was initially funded for 12 months and extended by a further 6 months, owing to positive feedback and expansion to other sites. A band 8a pharmacist and a band 6 medicines management pharmacy technician (MMPT) delivered structured telephone follow‑up calls.

Follow‑up was intended within two to three days of discharge, but calls were typically completed five to seven days post‑discharge, offering valuable insight into how patients manage their medicines once settled back into their home environment.

Between August 2024 and January 2026, 1,995 patients were contacted: 588 calls resulted in at least one intervention, 870 required no intervention as patients demonstrated understanding of their medicines, and 537 were unanswered or followed up by another service. These findings support the national discharge medicines service ambition to reduce medicines‑related harm and readmissions through enhanced pharmacy involvement after discharge.

The intervention

Eligible patients were proactively identified at discharge and offered a structured telephone consultation. The consultation focused on: 

• Confirming the patient’s understanding of medication changes; 
• Checking adherence and practical administration; 
• Exploring side effects and interactions; 
• Identifying duplicate or inappropriate therapy; 
• Resolving supply issues. 

Where concerns were identified, these were escalated to ward teams, GPs or community pharmacists, with clear documentation and safety‑netting advice provided to patients.

Common interventions included:

• Providing counselling for patients discharged on dual antiplatelet therapy or triple therapy, including duration and bleeding risk;
• Correcting anticoagulant doses to ensure patients received safe and effective therapy;
• Resolving dose errors with low‑molecular‑weight heparins and clarifying venous thromboembolism prophylaxis duration;
• Addressing inappropriate opioid use and reinforcing opioid stewardship principles;
• Supporting patients with language or health‑literacy barriers, often requiring family involvement or interpreter support.

Hospital discharge frequently involved multiple medication changes, limited opportunities for meaningful counselling and inconsistent transfer of information across care settings. Locally, recurring issues included dose errors, duplicate therapy, non‑adherence linked to lack of understanding or language barriers and medicines supply failures. Importantly, many of these issues only became apparent once patients had begun using their medicines in the community, rather than at the point of discharge.

Implications for pharmacy practice

Although 870 contacts required no intervention, these calls provided reassurance that medication changes were understood and appropriately implemented. This highlighted the value of post‑discharge follow‑up beyond error detection alone.

Effective use of the pharmacy team’s skill mix was central to service delivery: the MMPT led structured checks and provided patient education, while pharmacist input provided complex clinical decision‑making and appropriate escalation. Overall, pharmacy‑led post‑discharge follow‑up enabled early identification of clinically significant medicines‑related issues, supported behaviour change, and strengthened communication between secondary and primary care.

What next?

Post‑discharge medicines‑related risks are multifactorial and system‑level, arising from time pressures, capacity issues, incomplete or inaccurate documentation and variable discharge quality; no single intervention can realistically address these issues in isolation. Future service development work should focus on translating service outputs into meaningful metrics, such as estimated harm avoided, prevented appointments or admissions, patient‑reported understanding and examples of serious risk averted. Aligning the service with integrated care board priorities is essential to support long-term sustainability, secure recurrent funding or embed post‑discharge medicines counselling within core pharmacy services.

Panagiotis Nikolaidis, senior pharmacy technician, London North West University Healthcare NHS Trust

Gemini Patel, lead pharmacist, acute and emergency medicine and post-discharge counselling, London North West University Healthcare NHS Trust