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What is the challenge your project is going to address and how does it connect to your chosen theme?

Miscommunication is a leading cause for adverse events resulting in death or serious injury to patients. Mounting evidence has led the WHO to list improved communication in handover in its top five patient safety solutions. Patients can be handed over up to 15 times during a five day admission, receiving an overwhelming amount of verbal information which is hard to assimilate or retain. Non-adherence and risk of harm increases when patients do not fully understand the reasons for medication changes. Around a third of adverse drug events following discharge are preventable, with failure to monitor being a common cause, and patients with discrepancies in discharge information are more likely to be readmitted. Patients often identify opportunities to improve services: the patient is the only person who experiences the whole “medication journey”, and their voice needs to be heard.

What does your project aim to achieve?

The project will explore novel uses of technology and a change of focus from ‘never’ to ‘always’ events to improve communication around medication. Facilitated group discussion will enable patients and carers to develop a template of information required at transitions of care. Patient Experience logs or audio/video diaries of medication journeys will capture verbal information that would otherwise be ‘lost’, and record any concerns. Recordings can be used to ‘listen again’, or share with carers who manage medication, to improve understanding and adherence. Measures will include patient and carer experience and improvement in agreed domains of information transfer e.g. awareness of side-effects and warning signs, follow-up actions, and safe disposal of unused medication. Community pharmacist activity will identify further improvement, e.g. reduction in discrepancies; time spent reconciling discharge medication with GP repeat prescriptions, and patient counselling.

How will the project be delivered?

The project team will include Q members with experience of Experienced-based design with patients; PPI leads, patients and carers, NUH Medicines Safety Group members and CCG pharmacists. We will engage with patient participation groups and staff in primary and secondary care to achieve a collaborative, cross-boundary, inclusive consensus approach to communication around medication management. The project facilitator will use a tried and tested Experience Based Co-design method with larger groups to enable patients and carers to take the lead in shaping the project outputs. Volunteer patients and carers will create a log of a “medication journey”. Information exchange will be assessed according to the agreed template. Community pharmacists will build on an initiative to look at repeat prescriptions to identify areas of improvement.

What and how is your project going to share learning throughout?

Learning from this project will be widely applicable and can be shared via the Q community and in wider forums, e.g. IFQSHC. Updates will be shared on a regular basis via Project A3 reports to illustrate progress on project measures. With permission, patient diaries may be shared with primary and secondary care staff to identify any further ‘gaps’ in communication and demonstrate learning and improvement from ‘what goes right’.

How you can contribute

  • Measures, measures, measures! Advice about level of consent required, and how to go about this, and costings, please.


  1. I love this idea, it’s so creative. I would use the EBCD process to help define the measures that matter the most to patients and carers, testing them as part of your PDSA cycles when implementing.

    Good luck with it!

    best wishes


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