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Unintentional omissions and duplicate prescriptions occur during transfers of care, especially with time-critical medicines and complex or changing regimens.
Compare what the patient actually takes with the hospital drug chart, including medicines from other services, OTC products, allergies and recently stopped treatments.
Verify sources with the patient or carer, repeat prescription records, pharmacy and recent discharge letters. Prioritise immediate clarification of insulin, anticoagulants, Parkinson medicines, antiepileptics, steroids and clozapine.
Document the best possible medication history, intentional changes, last doses, monitoring needs and unresolved discrepancies; seek pharmacist involvement and hand over pending checks.
Never equate a GP repeat list with medicines definitely administered. A discrepancy may be an intentional change and requires explanation rather than blindly restoring old drugs.
UK reference: NICE NG5 medicines optimisation. Focused editorial source check, 7 November 2026; this is not independent clinical or pharmacy sign-off. Verify current local policy, BNF/BNFC and specialist advice before treatment. Not a prescribing protocol.
Related guides: Time-critical inpatient drugs โ ๏ธ ๐ ยท Discharge prescribing safety โ FY quick guide โ ๏ธ ๐