Since 2018, as one of the AHSN Network’s national adoption and spread programmes, Transfer of Care Around Medicines (TCAM) has been an important medicines safety project for the West of England AHSN.

Upon discharge from hospital, 30-70% of patients experience unintentional changes to their medications or an error is made because of a miscommunication. 37%1 of older patients experience medication related harm within eight weeks of discharge. This was estimated to cost the NHS £396m per year. These errors can also result in patients being readmitted to hospital.

TCAM identifies patients in hospital who need additional support with their medicines, often people using multi-compartmental compliance aids. These patients are referred for pharmacy input in the community.

We know through our recent project work commissioned via the national network of Patient Safety Collaboratives that medication errors in care homes is a significant issue, and that residents medications upon discharge from hospitals are a consistent concern nationally.

The COVID-19 pandemic brought a renewed focus from NHS England and a national call to action for the NHS to support the “provision of pharmacy and medication support to care homes”.  Building on the communication system utilised to deliver the TCAM project, our response pivoted to supporting reviews of new care home residents or those recently discharged from hospital by sending messages directly to community based pharmacy teams that support care homes with their medicines management.

Working collaboratively with member organisations and commissioners, the West of England AHSN is testing the hypothesis that utilising the TCAM communication system to refer to pharmacy teams that support care homes will mirror the impact identified in the nationally commissioned programme and reduce medication errors and potentially reduce readmission rates1,2,3,4.

Our medicines optimisation programme benefits from active and experienced colleagues from member organisations who form the Medicines Safety Steering Group. Through this group, experience and understanding was utilised to build on the original TCAM programme for the benefit of care home residents. In responding to our commissioner’s renewed focus, the collaborative and cross-system nature of AHSNs was demonstrated by the implementation of this project at pace in one regional trust.

Chris Learoyd, Project Manager said:

“Listening to our member organisations, care homes and understanding their needs and regional system(s) was crucial. The COVID-19 pandemic has changed many things, but the AHSN’s approach to project delivery has remained. The reactive, adaptive and collaborative practices required in responding to the COVID-19 pandemic have indeed drew-upon the AHSN’s approach: supporting healthcare innovation, quality improvement across the system; generating additional capacity, avoiding unnecessary costs whilst enhancing safety across the health and social care sector”.


  1. Sabir FR, Tomlinson J, Strickland-Hodge B, Smith H. Evaluating the Connect with Pharmacy webbased intervention to reduce hospital readmission for older people. International Journal of Clinical Pharmacy.
  2. Nazar H, Brice S, Akhter N, Kasim A, Gunning A, Slight SP, Watson NW. New transfer of care initiative of electronic referral from hospital to community pharmacy in England: a formative service evaluation. BMJ Open. https://doi:10.1136/bmjopen-2016-012532
  3. Mantzourani E, Nazar H, Phibben C, Pang J, John G, Evans A, Thomas H, Way C, Hodson K. Exploring the association of the discharge medicines review with patient hospital readmissions through national routine data linkage in Wales: a retrospective cohort study. BMJ Open.
  4. Wilcock M, Sibley A, Blackwell R, Kluettgenas B, Robsen S, Bastian L. Involving community pharmacists in transfer of care from hospital: Indications of reduced 30-day hospital readmission rates for patients in Cornwall. International Journal of Pharmacy Practice.  http://doi:10.1111/ijpp.12603

Posted on August 26, 2020

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