Discharged patients should be encouraged to tell a pharmacist if their medicines were changed in hospital, Nice has said.

Pharmacists with "relevant clinical knowledge and skills" should be involved in discussions about a patient's medicines "at any point of the care pathway", Nice said in a draft version of its first guidance on medicines optimisation published on Friday (October 10).

In the guidance, which is open for consultation until November 7, Nice described communication about the medicines of patients transferred between care settings as "ad-hoc and unreliable".

"Even when information about medicines is communicated, it is not always dealt with in a timely way. Patient safety must be the utmost priority and there is a risk to patient care when complete and accurate information about medicines is not transferred effectively between care providers," Nice said.

Patients needed to be "actively involved" in any discussion about their medicines needs or when their care was transferred to another provider. They should be provided with an accurate list of medicines in a "patient-friendly format", such as a hand-held device or a "medication passport", it said.

Although not all patients have a nominated community pharmacy, information of any medicine changes made in hospital should be sent to a pharmacist when possible "for safety purposes", Nice recommended. These discharge summaries must be communicated securely - ideally electronically - and with the patient's permission, it stressed.

This information should include relevant contacts – such as a nominated community pharmacy – as well as details of any allergies or medicine changes, and the date and time of the patient's last dose, Nice said. 

Discharged patients should also undergo a process of "medicines reconciliation" - where their current medicines were compared to a list made before they entered hospital - to check for any discrepancies, Nice advised. This should be carried out by a "competent" health professional, such as a pharmacist or pharmacy technician, and organisations should consider using a "senior, responsible pharmacist" to oversee the process, it recommended.  

Older patients, as well as those on multiple medicines or with long-term conditions, may benefit from pharmacist counselling when they were discharged from hospital, it added.

The final guidance is due to be published in March 2015.