One of the core tasks that our pharmacist is to undertake at the practice is medicine reconciliation. In his first week working in the practice our pharmacist is sent a patient discharge to reconcile. This discharge involves quite a few changes to the medication regime largely due to the fact that the patient in question had a stroke recently. The patient is to be initiated on an oral anticoagulant.
Our pharmacist misses this fact and fails to draw this change to the attention of the GP. The pharmacist deals with all the discharges and there is no system in place to workflow the discharge to the GP in this practice.
The patient presents at the GP practice to make a complaint after visiting his consultant a few days earlier. This encounter happened 6 months after his initial discharge from the hospital. Unfortunately, he had not been prescribed the oral anticoagulant for 6 months. Whilst his risk of subsequent stroke was likely increased luckily he did not have a second stroke and was initiated on an oral anticoagulant by the consultant cardiologist.