Clinical FeaturesInnovationPharmacy

Discharge Medication (TTO) Service: Bridging the Gap

Written by Patrick Foley, Head of Pharmacy, Blackrock Health at The Hermitage Clinic


The philosophy of the Hermitage Clinic at Blackrock Health is one of service and an acknowledgement of the holistic needs of patients, not just from a clinical perspective but also from a psychological, emotional and spiritual perspective also. In an effort to improve patient outcomes as well as providing a convenient service to patients, The Pharmacy Department launched the Discharge Medication (TTO) Service in 2021.

This new service aimed to bridge the gap between primary and secondary care, easing the transition for the patient from one setting to the other and aimed to replicate the National Health Service (NHS) provision of medication on discharge from hospital. The service provides for clinical pharmacist reconciliation of patient medicines on admission and discharge, and see’s pharmacy staff counsel patients at their bedside with their new medications in-hand as a visual prompt.

Benefits to the patient include a clinical pharmacist who is trained to interpret biochemical results and their effects on pharmacokinetics providing a ‘clinical screen’ of discharge medication with subsequent inhouse dispensing of the discharge prescription. In addition to this, the patient no longer has to find a community pharmacy that may or may not be open on their way home. This is not only convenient for the patient but also reduces any delays to the administration of time sensitive medications.


A variety of clinical pharmacy services exist across the international healthcare landscape. Irish clinical pharmacy services are increasingly getting recognition for the wonderful output of clinical pharmacists in the secondary care setting. With more specialist roles being recognised and funded in Ireland e.g. Cystic Fibrosis or Hepatitis C Specialist Pharmacists, we are beginning to mimic frameworks that have existed in the NHS for some time. Another component of the NHS clinical pharmacy service is the pharmacist clinical screening, and subsequent provision of, medications on discharge, coined ‘To-Take-Out’ or ‘TTO’ medications. This service aims to recognise the potential multitude of changes to regular medications patients may experience during their inpatient stay, and to assess whether acute (or temporary) medications can be safely taken by the patient alongside their regular medication.

Clinical pharmacists will make several interventions during the course of their day in order to optimise the prescribing and administration of medicines and reduce the incidence of harm. These may relate to simple prescribing errors like incorrect dosing, omitted drugs or contraindications. Interventions may also relate to the pharmacokinetic principles of medication which include the patient’s ability to absorb, distribute, metabolise, and excrete prescribed medications. During a hospital stay patients will commonly experience altered physiological states as a result of a variety of occurrences (e.g. blood loss post-op, infections etc). These changes will alter the patient’s abilities when it comes to pharmacokinetic principles. The interpretation of blood results for predicting a patient’s ability to excrete medication is a key part of a clinical pharmacist’s daily routine. With this information potentially unavailable to a community pharmacist when presented with a prescription, it means the same calculations cannot be completed and a potentially important second check may not be possible.

Senior management within the Hermitage Clinic recognised the importance of bridging the gap between primary and secondary care and approved the business case for the implementation of a TTO-style service known as the “Discharge Medication Service”. One WTE pharmacy technician was appointed to assist with the dispensing of the discharge medications once they were screened by a clinical pharmacist. This appointee has been able to support trained medicines management pharmacy technicians and clinical pharmacists in counselling patients wishing to avail of the service.


A systematic review of quantitative literature relating to medication reconciliation at discharge from hospital was conducted in 2015 by Irish researchers. They found that among the 15 studies, 60% of the over 6000 patients, experienced a medication discrepancy on discharge from hospital. One of the studies breaks down likelihood of experiencing a medication discrepancy by age. Those over 75 years of age were almost twice as likely to experience medication discrepancies as patients under 60. This could be related to the requirement on patients with potentially reduced cognition to interpret written or verbal instructions on discharge from hospital which may differ between doctor’s intentions, discharge summary, and eventually prescription for dispensing.

This data was strongly backed up by findings in the NHS by the National Patient Safety Agency (NPSA) who described 30-70% of patients as experiencing an error or unintended change to their medicines when transitioning through care settings. A collaborative service evaluation across 50 acute care trusts examined 8,621 patient’s prescribed medications and found 11,366 unintentional discrepancies, or 1.32 per patient. The Royal Pharmaceutical Society produced a report in 2012 titled, “Keeping patients safe when they transfer between care providers – getting the medicines right”, in an attempt to reduce the incidence of medication errors when patients are for example discharged from hospital. The report outlines key principles, responsibilities, and recommendations for effective transfer of medication information when discharging patients.

The National Institute for Health and Care Excellence in their Medicines Optimisation guidance describe the importance of medicines related communication systems when patients move from one care setting to another. They state that organisations should ensure robust and transparent processes are in place. They also provide definitions of what robust and transparent processes must look like. The discharge system should ensure that patient safety is not compromised. Inappropriate care may result from inconsistencies in processes.

Effect on organisation

While the initiative is still in its infancy, a number of benefits to patients and the organisation have already been noted.

Improvements in Medication Safety for patients

Due to the enhanced role of the clinical pharmacist in reviewing medications on discharge, a number of potential medication incidents have been identified before the patient leaves the hospital. These incidents have ranged from relatively straightforward omissions of regular medication to contraindications and even the prescribing of non-steroidal anti-inflammatory medication to patients with chronic kidney disease.

Increased efficiency at ward level

A portion of the clinical pharmacist interventions would no doubt be picked up in the community. Often these may have related to omissions of medications or unclear plans in relation to for example tapering doses of medications. Previously this would have involved phone calls being placed by busy community pharmacists to the ward the patient may have been on. A nurse would then have had to contact the patient’s consultant for clarity and then relay this message back to the community pharmacist. This process invariably took many hours of time to resolve often resulting in delays to the provision of treatment to the patient in the community as well as adding to the nurse and community pharmacist’s workload. The introduction of the Discharge Medication Service has resulted in a decrease in such incidents

Improvements in antimicrobial stewardship

With a knowledge of the hospital’s antimicrobial guidelines and vital clinical information available to the clinical pharmacist numerous interventions relating to antimicrobial stewardship became evident e.g. a patient had sensitivity information available detailing they were resistant to the prescribed medication on discharge, the pharmacist was able to intervene and have alternative therapy prescribed. With discharge dispensing data now available to the hospital we can comment on and audit our provision of oral antibiotics. With this information not previously being available we can further improve our antimicrobial stewardship.

Similarly, our provision of analgesics and hypnotics was now auditable from a central database. A significant volume of elective orthopaedic procedures are carried out at the Hermitage Clinic. The provision of potentially harmful potent opioid medications has gained great notoriety in the past decade particularly in the United States. It became apparent that we very rarely issue these types of medications on discharge, and when we do they are for a defined period, usually 72 hours.

Commercial Opportunities

The provision of a TTO service is already standard in the NHS and is also a requirement by them for any third parties providing care to NHS registered patients. The introduction of the Discharge Medication Service has allowed the Hermitage to bid for contracts to provide care to patients who reside in Northern Ireland. These contracts require a service akin to that which exists in the NHS and therefore a 14 day supply of medication is made on discharge. This has led to an increase in the number of agreements the Hermitage has with Hospital Trusts in NI resulting in an increase in revenue across various relevant departments.

Revenue Generation

The project has generated revenue in the form of patients paying for their private prescriptions to be dispensed. These costs are comparable to those that would be paid in the community and often the patient will choose to avail of the service due to the overwhelming convenience. Patient’s will often cite the need to find a community pharmacy, find parking and queue up and wait in the shop as a motivation for availing of the service. The project although in its infancy, has already produced a positive net present value since uptake continuing on an upward trajectory. There are also substantial increases in revenue related to the organisations’ ability to bid for and fulfil NHS contracts.

Plans going forward

The Hermitage Clinic will continue to promote the service throughout the hospital. An information campaign is already in process that see’s patients being made aware of the service on admission. Patients are provided a patient information leaflet relating to the service, which outlines the benefits and what the service entails. It is anticipated that these measures will increase the uptake of the service, increase patient satisfaction and lead to growth in revenue generation for the pharmacy department and from gaining NHS contracts. The hope is that the new discharge medication (TTO) service will become embedded within the culture of the organisation.

While the hospital will continue to provide the service and encourage as many patients as possible to avail of the service owing to its convenience for them, the service does not currently provide medications free of charge for medical card holders or patients on long term illness plans. We will look to address this as the service develops so that the scope can become more far-reaching. Another hurdle within the provision of the service is the requirement for the input of the clinical pharmacist on the ward to screen the discharge medications prior to dispensing. The requirement adds a new work stream for the clinical pharmacist. But on balance the improvement to medication safety, and the decrease in potential complications and resultant phone calls back to the ward to clarify ambiguities, make it a worthwhile endeavour for the clinical pharmacist.

Costs are another obvious concern to any organisation wishing to embark on similar plans, but these may be underwhelming. The Hermitage Clinic found that per discharge the cost of the drugs supplied to patients availing of the service was around ¤14. As is the case in the NHS, a targeted ‘discharge formulary’ to avoid high-tech or very high cost medicines could be agreed upon which would aid a similar roll-out in the public sector. There is also a potential scope for revenue generation in the public sector for the cohort of patients that do not avail of HSE schemes.

Initial feedback from patients is overwhelmingly positive, with most citing the convenience of the service as the most positive aspect. All of these factors make a compelling argument for the roll out of the service in other Blackrock Healthcare sites. Plans are currently at draft stage and it is expected that they will be positively reviewed with a view to implementation at some point in the future. We would hope that the success of this service in a private sector acute hospital may prompt the question as to how it could be rolled out in other hospitals, including public hospitals, and how the Hermitage Clinic could inform this discussion and assist with implementation plans?

A similar provision in the public sector would vastly improve medication safety at a key transition of care. Irish researchers in a 2015 review of published data relating to medication reconciliation at discharge identified the incidence of medication discrepancies at the point of discharge from hospital as a ‘problem and one that the healthcare system needs to address’. Some improvements and attempts to address the problem have been made since that review was published, but widespread introduction of a discharge medication service where patient’s prescriptions are routinely screened by Clinical Pharmacists with hospital provision of medication would be a significant step forward.

The TTO service has been a tremendous improvement to medication safety, patient convenience and efficiency, and it is a service which will be embraced by Blackrock Health at the Hermitage Clinic long into the future.

Medication safety is paramount at every stage of the patient’s journey, and research has shown the positive effects of pharmacist-led medication reviews on inpatient adverse drug events. Extending this service to the screening of discharge prescriptions can further improve medication safety, due to the prevalence of medication errors on transfer of patients from secondary to primary care. The provision of a Discharge Medication Service (‘TTO’ service) adds a safety screen for patients on discharge. It allows for medication reconciliation on discharge and identifies any potential errors, interactions and monitoring requirements. It can aid patients’ understanding of their discharge medications, as well as the added convenience of providing them with their discharge medications before leaving hospital.

In my experience from working in hospital pharmacy in both the UK and Ireland, screening of the discharge prescription by a clinical pharmacist – and indeed writing of the discharge prescription by a pharmacist prescriber – is common practice in the UK, but is yet to become a core service provided by clinical pharmacists in Ireland. Expanding the pharmacy service required a change in practice from the entire pharmacy team from their traditional roles of inpatient medication review and supply, including the dispensary team, Medication Management Pharmacy Technicians (MMPTs) clinical pharmacists and the wider hospital staff.

Though the service is still in its development, it has been perceived positively by patients, particularly by our younger surgical patients and day procedure cohort, who pay privately for their medications. The service has also brought its own challenges and limitations. The service requires more clinical pharmacist and dispensary staff time and puts more onus on the pharmacy department to allow a safe and timely discharge for patients. Patients may prefer to visit their own community pharmacy to avail of the medication schemes available such as GMS and DPS which for the moment are unavailable form the hospital.

Examples of recent interventions on discharge include the prevention of potentially elevated clozapine levels by co-administration of celecoxib; preventing the use of ferrous fumarate in a patient with family history of haemochromatosis; stopping tramadol in a patient with history of seizures and stopping the unintentional prescribing of aspirin to a patient who regularly takes a DOAC.

– Clodagh Dolan, Senior Pharmacist

I believe the novel and unique Discharge Medication Service provided by Blackrock Health at the Hermitage Clinic is an essential service that is paramount to delivering the final step of a completed healthcare experience for patients admitted to hospital. This is a highly beneficial service for patients who can conveniently and comfortably obtain supply and thorough counselling of their discharge medications, by experienced pharmacists, medicines management technicians and Pre-reg pharmacy students.

As a Pre-Reg pharmacy student operating within this service, I play a role in initially reviewing the prescription ensuring it is legally valid and that it is therapeutically appropriate for the patient, prior to the pharmacist’s clinical screen. Once I have completed dispensing the discharge medications, it then undergoes a final accuracy check in the dispensary prior to being released. I then play a huge part in counselling patients on their prescribed medication ensuring that I communicate effectively and confirm a counselling checklist which includes: their understanding on the use of the medicine, directions for use, how to administer it, duration of treatment, expected therapeutic benefit, potential side effects, any special precautions including those regarding food or drink, importance of compliance, storage and the correct use of a therapeutic device if applicable.

My current role in the discharge medication service did not begin however until I had completed thorough training under the supervision of highly qualified and experienced pharmacists within our pharmacy department. I first had to ensure that I could competently dispense a variety of prescription types without mistakes and counsel patients at their bedside on a diverse range of medications while being supervised. This experience has been invaluable as it has allowed me to gain a huge insight into the counselling requirements for patients on high risk medications such as apixaban. I have become very confident when speaking to patients and have learned a significant amount particularly in relation to high risk medication like apixaban.

I believe this is a remarkable service which should be employed in Irish hospitals nationwide to optimise the delivery of healthcare to patients and to enhance the training of Pre-Reg pharmacy students.

– Clodagh McDermott, Pre-Reg (APPEL) Pharmacist

Undertaking my pre-registration placement at the Blackrock Health Group at the Hermitage Clinic (HMC) has given me the advantage of having an active involvement in the TTO (discharge medication) service. As this is my first placement in a hospital I was shocked to hear that such a service isn’t in place in every hospital; it makes perfect sense. Aside from the convenience of getting to go straight home, avoiding queues and parking-having a prescription dispensed in the HMC involves a clinical screen of the discharge prescription, with the patient’s clinical details readily available.

In order to be involved in the TTO service without being a qualified pharmacist I was required to complete various competency logs. Counselling sessions were observed by a pharmacist to prepare us, these witnessed counselling episodes had to contain as a minimum dose titrations of steroids, a NOAC, inhaler use, insulin administration and initiation and many more scenarios. A summary of the counselling had to be written into our log book including what went well, what could be improved upon and any learning points. Once completing the logs we were deemed eligible to dispense TTO prescriptions, once a pharmacist carried out a final check, and then counsel patients at their bedside. We could then take the medication to the patient and engage in counselling ourselves. The involvement in such a service has been highly beneficial to my training as a pre-reg pharmacist, without it I may not have the experience of considering a patient’s situation beyond discharge or being involved in their education.

I now believe it to be really important that patients receive a clinical pharmacist screen on discharge from hospital. I have seen numerous pharmacist interventions made for patients prescribed NSAIDs with diminished renal function for example. Prior to commencing a hospital placement I was apprehensive about the possibility of there being less patient counselling experience which I need to complete my final OSCE. The experience however is the opposite, at the Hermitage pharmacy department I am at the patient’s bedside on a daily basis helping them in their transition back to primary care. I will carry with me the learning I have gained from being involved in this service well into my future career.

– Chloe Breen, Pre-Reg (APPEL) Pharmacist

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