The discharge of a multimorbid patient is the moment medication errors cluster, and it is also the best chance to deprescribe. A structured reconciliation against the pre-admission list catches the drugs stopped in hospital that were never restarted, and the ones started for an acute problem that should not continue.
Look actively for the common culprits: a proton-pump inhibitor begun for stress-ulcer prophylaxis, a sedative or antipsychotic started for inpatient delirium, an analgesic escalated during the admission, and duplicate or interacting agents accumulated across specialties. Each needs an explicit decision to continue, stop or taper, with the plan written for the patient and the general practitioner.
The habit worth keeping is to treat every discharge as a deprescribing opportunity, not only a prescribing one, and to communicate the reasoning so it is not quietly reversed in the community.
- Reconcile the discharge list against the pre-admission list, both additions and omissions.
- Stop stress-ulcer proton-pump inhibitors that have no ongoing indication.
- Review sedatives or antipsychotics started for inpatient delirium for prompt tapering.
- Resolve duplicate or interacting drugs accumulated across specialty teams.
- Write the reasoning for each change so the community team does not reverse it.
Why it matters
Discharge is where medication errors cluster and where unnecessary drugs become permanent if nobody stops them.
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