Medication therapy changes refers to changes to the patient's preadmission medication regimen that are intended to continue after discharge. Changes may include: • initiation of a new medicine • change in the dose, form, route or frequency of a medicine taken prior to admission • cessation of a medicine taken prior to admission • recommencement of a medicine that was intentionally withheld prior to admission If there are no changes to the patient's preadmission medication regimen as a result of hospital admission, this should be explicitly documented. Explanations for changes should include sufficient detail to inform future management decisions and should be explicitly documented in the discharge summary or discharge letter.

Number of discharge summaries that include medication therapy changes and explanations for changes

Number of discharge summaries in sample

None

Medical records, medication charts, medication management plans or reconciliation forms, discharge summaries and discharge prescriptions. Differences between admission and discharge medicines should be assumed to represent medicine therapy changes.

Recommended for local quality improvement processes. Not regularly reported at national level.

Australian Commission on Safety and Quality in Health Care and NSW Therapeutic Advisory Group Inc. (2014), National Quality Use of Medicines Indicators for Australian Hospitals. ACSQHC, Sydney www.safetyandquality.gov.au/sites/default/files/migrated/SAQ127NationalQUMIndicatorsV14-FINAL-D14-39602.pdf page 88