{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,18]],"date-time":"2026-07-18T18:16:38Z","timestamp":1784398598588,"version":"3.55.0"},"reference-count":78,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2023,1,1]],"date-time":"2023-01-01T00:00:00Z","timestamp":1672531200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Kuwait Civil Service Commission"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Therapeutic Advances in Drug Safety"],"published-print":{"date-parts":[[2023,1]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction:<\/jats:title>\n                    <jats:p>Improving medication safety during transition of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim:<\/jats:title>\n                    <jats:p>To characterise the nature and contributory factors of medication-related incidents during transition of care from secondary to primary care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method:<\/jats:title>\n                    <jats:p>A retrospective analysis of medication incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019. Descriptive analysis identified the frequency and nature of incidents and content analysis of free text data, coded using the Patient Safety Research Group (PISA) classification, examined the contributory factors and outcome of incidents.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>A total of 1121 medication-related incident reports underwent analysis. Most incidents involved patients over 65 years old (55%, n\u2009=\u2009626\/1121). More than one in 10 (12.6%, n\u2009=\u2009142\/1121) incidents were associated with patient harm. The drug monitoring (17%) and administration stages (15%) were associated with a higher proportion of harmful incidents than any other drug use stages. Common medication classes associated with incidents were the cardiovascular ( n\u2009=\u2009734) and central nervous ( n\u2009=\u2009273) systems. Among 408 incidents reporting 467 contributory factors, the most common contributory factors were organisation factors (82%, n\u2009=\u2009383\/467) (mostly related to continuity of care which is the delivery of a seamless service through integration, co-ordination, and the sharing of information between different providers), followed by staff factors (16%, n\u2009=\u200975\/467).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion:<\/jats:title>\n                    <jats:p>Medication incidents after hospital discharge are associated with patient harm. Several targets were identified for future research that could support the development of remedial interventions, including commonly observed medication classes, older adults, increase patient engagement, and improve shared care agreement for medication monitoring post hospital discharge.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Plain language summary<\/jats:title>\n                    <jats:p>Study using reports about unsafe or substandard care mainly written by healthcare professionals to better understand the type and causes of medication safety problems following hospital discharge Why was the study done? The safe use of medicines after hospital discharge has been highlighted by the World Health Organization as an important target for improvement in patient care. Yet, the type of medication problems which occur, and their causes are poorly understood across England and Wales, which may hamper our efforts to create ways to improve care as they may not be based on what we know causes the problem in the first place. What did the researchers do? The research team studied medication safety incident reports collected across England and Wales over a 5-year period to better understand what kind of medication safety problems occur after hospital discharge and why they happen, so we can find ways to prevent them from happening in future. What did the researchers find? The total number of incident reports studied was 1121, and the majority ( n\u2009=\u2009626) involved older people. More than one in ten of these incidents caused harm to patients. The most common medications involved in the medication safety incidents were for cardiovascular diseases such as high blood pressure, conditions such as mental illness, pain and neurological conditions (e.g., epilepsy) and other illnesses such as diabetes. The most common causes of these incidents were because of the organisation rules, such as information sharing, followed by staff issues, such as not following protocols, individual mistakes and not having the right skills for the task. What do the findings mean? This study has identified some important targets that can be a focus of future efforts to improve the safe use of medicines after hospital discharge. These include concentrating attention on medication for the cardiovascular and central nervous systems (e.g., via incorporating them in prescribing safety indicators and pharmaceutical prioritisation tools), staff skill mix (e.g., embedding clinical pharmacist roles at key parts of the care pathway where greatest risk is suspected), and implementation of electronic interventions to improve timely communication of medication and other information between healthcare providers.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/20420986231154365","type":"journal-article","created":{"date-parts":[[2023,3,16]],"date-time":"2023-03-16T08:46:52Z","timestamp":1678956412000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":20,"title":["Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study"],"prefix":"10.1177","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9714-0007","authenticated-orcid":false,"given":"Fatema A.","family":"Alqenae","sequence":"first","affiliation":[{"name":"Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Oxford Street, Manchester M13 9PL, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Douglas","family":"Steinke","sequence":"additional","affiliation":[{"name":"Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK"},{"name":"Pharmacy Department, Manchester University NHS Foundation Trust, Manchester, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Carson-Stevens","sequence":"additional","affiliation":[{"name":"Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7854-8154","authenticated-orcid":false,"given":"Richard N.","family":"Keers","sequence":"additional","affiliation":[{"name":"Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK"},{"name":"Suicide, Risk and Safety Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2023,3,16]]},"reference":[{"key":"bibr1-20420986231154365","volume-title":"Third global patient safety challenge: medication without harm","author":"World Health Organization (WHO)","year":"2017"},{"key":"bibr2-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1007\/s40264-020-00918-3"},{"key":"bibr3-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2020-010927"},{"key":"bibr4-20420986231154365","volume":"8","author":"Redmond P","year":"2018","journal-title":"Cochrane Database Syst Rev"},{"key":"bibr5-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1186\/s12911-016-0353-9"},{"key":"bibr6-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2017-007087"},{"key":"bibr7-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1136\/ejhpharm-2017-001441"},{"key":"bibr8-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1136\/ejhpharm-2015-000677"},{"key":"bibr9-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1001\/jamainternmed.2020.9285"},{"key":"bibr10-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1001\/jamainternmed.2021.7429"},{"key":"bibr11-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-020-05355-7"},{"key":"bibr12-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1007\/978-94-007-0753-5_3008"},{"key":"bibr13-20420986231154365","unstructured":"Department of Health. An organisation with a memory \u2013 report of an expert group on learning from adverse events in the NHS. https:\/\/qi.elft.nhs.uk\/wp-content\/uploads\/2014\/08\/r_02-an-organisation-with-a-memory-l-donaldson.pdf"},{"key":"bibr14-20420986231154365","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp15X687877"},{"key":"bibr15-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2015-004732"},{"key":"bibr16-20420986231154365","volume-title":"Risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care","author":"NHS England","year":"2014"},{"key":"bibr17-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1097\/PTS.0000000000000654"},{"key":"bibr18-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1080\/13814788.2018.1543396"},{"key":"bibr19-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1097\/PTS.0000000000000815"},{"key":"bibr20-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1007\/s40272-021-00442-6"},{"key":"bibr21-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1001885"},{"key":"bibr22-20420986231154365","volume-title":"Seven steps to patient safety \u2013 an overview guide for NHS staff","author":"National Patient Safety Agency","year":"2004"},{"key":"bibr23-20420986231154365","unstructured":"World Health Organization (WHO). Minimal information model for patient safety incident reporting and learning systems. www.impact-test.co.uk (2016, accessed 10 January 2022)."},{"key":"bibr24-20420986231154365","first-page":"22","volume":"18","author":"Alldred D","year":"2010","journal-title":"Int J Pharm Pract"},{"key":"bibr25-20420986231154365","unstructured":"Joint Formulary Committee. British National Formulary. London: BMJ Group and Pharmaceutical Press. www.medicinescomplete.com"},{"key":"bibr26-20420986231154365","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.17.199802"},{"key":"bibr27-20420986231154365","volume-title":"Statistical methods for NHS incident reporting data","author":"Mainey CP","year":"2020"},{"key":"bibr28-20420986231154365","volume-title":"et al. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice","author":"Carson-Stevens A","year":"2016"},{"key":"bibr29-20420986231154365","unstructured":"Carson-stevens AP. Generating learning from patient safety incident reports from general practice. https:\/\/orca.cardiff.ac.uk\/id\/eprint\/104070\/"},{"key":"bibr30-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1177\/0269216318776846"},{"key":"bibr31-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1097\/PTS.0000000000000530"},{"key":"bibr32-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1186\/s12873-019-0289-3"},{"key":"bibr33-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1016\/j.vaccine.2015.06.068"},{"key":"bibr34-20420986231154365","volume-title":"Implementing the NHS patient safety strategy: Safer culture, safer systems, safer patients","author":"NHS England and NHS Improvement","year":"2019"},{"key":"bibr35-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1345\/aph.1H658"},{"key":"bibr36-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1023\/A:1015570104121"},{"key":"bibr37-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2125.2006.02698.x"},{"key":"bibr38-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1097\/01.sa.0000412401.21757.36"},{"key":"bibr39-20420986231154365","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-147-11-200712040-00006"},{"key":"bibr40-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1111\/j.1532-5415.2007.01047.x"},{"key":"bibr41-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1001\/jama.296.15.1858"},{"key":"bibr42-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(11)61817-5"},{"key":"bibr43-20420986231154365","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp11X588501"},{"key":"bibr44-20420986231154365","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp14X677806"},{"key":"bibr45-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1177\/1062860612445070"},{"key":"bibr46-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1016\/j.sapharm.2018.09.009"},{"key":"bibr47-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1136\/ejhpharm-2020-002365"},{"key":"bibr48-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1007\/s11096-013-9813-9"},{"key":"bibr49-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1093\/ijpp\/riaa004"},{"key":"bibr50-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1016\/j.japh.2019.07.002"},{"key":"bibr51-20420986231154365","unstructured":"NHS. Discharge medicines service. https:\/\/www.england.nhs.uk\/primary-care\/pharmacy\/nhs-discharge-medicines-service\/ (2021, accessed 10 January 2022)."},{"key":"bibr52-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1111\/jep.12870"},{"key":"bibr53-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1177\/1060028019867253"},{"key":"bibr54-20420986231154365","volume":"10","author":"Khalil H","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"key":"bibr55-20420986231154365","volume-title":"Opening the door to change \u2013 NHS safety culture and the need for transformation","author":"Care Quality Commission","year":"2018"},{"key":"bibr56-20420986231154365","volume-title":"Administrative errors: technical series on safer primary care","author":"World Health Organization","year":"2016"},{"key":"bibr57-20420986231154365","first-page":"732","volume":"57","author":"Cox SJ","year":"2007","journal-title":"Br J Gen Pract"},{"key":"bibr58-20420986231154365","doi-asserted-by":"publisher","DOI":"10.3399\/bjgpopen18X101611"},{"key":"bibr59-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1007\/s11096-016-0349-7"},{"key":"bibr60-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1007\/s40264-015-0320-x"},{"key":"bibr61-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2019-010206"},{"key":"bibr62-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1111\/bcp.13613"},{"key":"bibr63-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1111\/jep.13494"},{"key":"bibr64-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-019-4447-9"},{"key":"bibr65-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1111\/hex.12516"},{"key":"bibr66-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1111\/hex.13029"},{"key":"bibr67-20420986231154365","doi-asserted-by":"publisher","DOI":"10.3961\/jpmph.16.105"},{"key":"bibr68-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2015-004049"},{"key":"bibr69-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1186\/s12875-018-0803-9"},{"key":"bibr70-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1111\/hex.13145"},{"key":"bibr71-20420986231154365","volume-title":"Global patient safety action plan 2021\u20132030: towards eliminating avoidable harm in health care","author":"World Health Organization (WHO)","year":"2021"},{"key":"bibr72-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1211\/pj.2019.20206131."},{"key":"bibr73-20420986231154365","volume-title":"Improving patient outcomes \u2013 the better use of multi-compartment compliance aids","author":"Barnett N"},{"key":"bibr74-20420986231154365","volume-title":"Summary of Guidance and Evidence for use of Multi-Compartment Compliance Aids (MCCAs)","author":"Specialist Pharmacy Service","year":"2019"},{"key":"bibr75-20420986231154365","unstructured":"NHS. Learn from patient safety events. https:\/\/record.learn-from-patient-safety-events.nhs.uk\/ (accessed 19 December 2021)."},{"key":"bibr76-20420986231154365","unstructured":"NHS. Learn from patient safety events (LFPSE) service. https:\/\/www.england.nhs.uk\/patient-safety\/learn-from-patient-safety-events-service\/ (accessed 19 December 2021)."},{"key":"bibr77-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2005.017616"},{"key":"bibr78-20420986231154365","doi-asserted-by":"publisher","DOI":"10.1016\/j.apergo.2020.103339"}],"container-title":["Therapeutic Advances in Drug Safety"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/20420986231154365","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/20420986231154365","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/20420986231154365","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T23:40:11Z","timestamp":1777592411000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/20420986231154365"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,1]]},"references-count":78,"alternative-id":["10.1177\/20420986231154365"],"URL":"https:\/\/doi.org\/10.1177\/20420986231154365","relation":{},"ISSN":["2042-0986","2042-0994"],"issn-type":[{"value":"2042-0986","type":"print"},{"value":"2042-0994","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,1]]},"article-number":"20420986231154365"}}