Less than half of the discharge summaries for elderly patients with many drugs were received, although they are meant to inform the patient as well as the next caregiver about drug changes made during hospital admissions. In the survey, more than one-third reported the discharge summary was never/seldom received, regardless of the time span. Furthermore, almost two-thirds in the survey indicated that they always/often updated medication list/made patient chart entries upon receipt of the discharge information. However, the medical record investigation showed that after drug changes, only one third of medication lists were updated in primary care medical records after two weeks. Patient chart entries regarding medication or its follow-up were only seen in primary care medical records in every other case.
The average age of patients in this study was 86 years old and used five or more drugs. People of this age are vulnerable and often use many drugs [7, 8], with an accordingly high risk of adverse drug reactions and hospitalisation [9, 11]. Drug-related problems are common after hospital discharge , and drug-related readmissions are frequent . A discharge summary with a medication report improves medication use [13, 14, 16, 23]. However, to fully exploit its potential the discharge summary must be adequately transferred and received, which was seen in only about 40% of cases in this study. Poor communication and information transfer in care transitions and being perceived negatively by the GPs and contributing to medication errors have also been shown previously [25,26,27,28]. In a Swedish National board of health and welfare survey , only around half of the primary care units received information on medication initiated during hospitalisation, more commonly through medical case histories than medication reports . Information transfer often took at least a week, sometimes even more than two weeks . As expected, this study had a larger proportion of transfers since inclusion was actual discharge summaries. Nevertheless, the transfer of discharge summaries was still inadequate. Furthermore, the discharge summary should also be immediately transferred to the next caregiver. Thus, although a prolonged time period might have allowed for a greater number of discharge summaries being found, we consider this less likely. Although some studies show no difference in GPs satisfaction with electronic discharge summaries , others clearly demonstrate improved satisfaction regarding both quality and timeliness [30,31,32]. Even electronically produced discharge summaries may still be manually transferred. As in our study, the electronic discharge summaries in the study by Alderton and Callen were printed and mailed to the GP . However, electronic transfer was called for, deemed desirable if doable . While electronic preparation may result in improved discharge summaries, it still relies on the information derived from the electronic medical records being adequate. However, increased electronic management may help improve information transfer in care transitions. A secure way of transferring the discharge summaries electronically may prevent delays in their delivery to primary care. An electronic system may also enable security check-points such as automated reminders to hospital physicians to write and send the discharge summary, as well as compulsory receipts from primary care upon receiving the discharge summaries.
In this study, medication lists were not satisfyingly updated after drug changes, although the survey respondents reported updating more frequently. Similar to our results, a recent study from the Netherlands showed one third of in-hospital prescription changes was not or incorrectly documented in the primary care medical record , which is in line with a previous study on post-discharge medication-related information . According to previous Swedish and American studies, discrepancies between the patients’ intended medication regimen and the medication list in primary care are common [35,36,37], even with a common medical record [35, 36], and the need for great improvement regarding updated medication lists was noted . An accurate medication list is essential to assess the patient’s symptoms as well as the risks and effects of treatment . Failure to update the medication list could possibly result in medication errors. A large share of medication errors is potentially harmful [39, 40] and may lead to preventable adverse drug events . A poorly updated medication list might also partly result from the well-known occurrence of medication errors in discharge summaries  and a lack of important drug-related information [26, 34, 43]. Although many survey respondents viewed the medication report as reliable and clear and the discharge summary of great help for medication follow-up, many had experienced lack of reason for drug changes in the medication report thus possibly affecting the GPs’ attitude towards updating the medication list. Piecing the information together is also very time consuming. The type of drug that was changed may also affect the update, since drugs may be viewed as being of different importance. However, although not examined in our study, a previous study of discrepancies in the medication list noted cardiovascular drugs as those that are most commonly affected , which are likely often of importance. Regardless, updating the medication list is an essential responsibility for any physician .
Making a patient chart entry and updating the medication list might be considered unnecessary; since the discharge summary is scanned into the primary care medical records. However, this means uncertainty concerning which list that is correct. Since clear routines are lacking it is likely up to the individual doctor if and when a patient chart entry is made, which is a national problem .
Routines for content and transfer of discharge summaries may reduce care transition medication errors [7, 28]. Primary care confirmation of the information transfer before taking over responsibility for the patient has been suggested . No current common routine on transfer and use of the discharge summaries exists in primary care in Sweden, merely general and guiding principles regarding medication management  as in some other countries [47, 48]. Although many of the survey respondents had discussed the topic, few had written a local routine. This may affect its use, i.e. updating the medication list and planning any follow-up.
Further, almost 30% reported never/seldom following up drug changes even if needed, which risks delayed detection of side-effects and other drug-related problems. The reasons behind abstaining from follow-up are not known. However, in the survey free text comments, the need for a formal referral for follow-up as well as lack of time to use the discharge summary was noted. Noting but not actively following up drug changes as well as insufficient time to update medication lists implies a risk of medication errors and drug-related problems. Targeting this may increase medication safety and reduce costs. The possibility of errors on admission was also highlighted. Keeping primary care medication lists accurate counteracts this. A common medication list for hospital and primary care was also proposed in the survey free text comments. Even though a common list could increase medication safety, this may fail due to unsatisfactory maintenance and frequent errors [35, 38]. In addition, hoping for a future common list does not eliminate the responsibility to keep current medication lists accurate. An inaccurate list is unreliable and unusable as well as potentially risky for the patient.
The strengths of this study are the two perspectives on studying information transfer, where the medical records review was complemented by the survey. Moreover, this study has a primary care focus on information transfer; an area that is not well explored in Sweden.
A possible limitation of this study may be the timeframe; the time period of two weeks may have contributed to the low share of updated medication lists and patient chart entries in the primary care medical records. However, despite possible delayed medical secretary writing and physicians’ heavy work burden, follow-up of these fragile patients should be initiated within this timeframe [8, 9]. Still, it is possible some GPs update the medication list at a later point in time, for example the patient’s next visit, which may affect medical safety. Furthermore, opinions of survey non-respondents (44 primary care units) are not known. It was advised to answer the survey in consultation with the chief physician. Hence, opinions of a single GP may be represented rather than those of all colleagues. As previously noted, GPs are often individualists that work in their own way, without the management leading the medical work . It is possible the non-respondents would report updating medication lists and making patient chart entries to a lower extent. However, the survey was not primarily sent to the physicians but the head of the primary care unit. Further, the survey examined their views of their actions, while the first part of the study examined the actual share of updated medication lists and included all primary care units receiving discharge summaries during the study period, regardless of whether they later answered the survey or not. Nevertheless, web surveys are commonly associated with low response rates, especially physician surveys , hence the response rate in our study is acceptable. Further, the survey reflected all discharge summaries while the review of the primary care medical records focused on elderly patients with many drugs. However, differing views on information transfer due to patient type was not expected.
Further improvement could result from electronic transfer of the discharge summary. Enhanced communication, possibly electronic, between hospital and primary care physicians before hospital discharge regarding for example medication changes as well as follow-up plans could also be beneficial. Also, efforts to improve information transfer at all stages, especially for elderly who are particularly vulnerable in care transitions, could be of value, such as adequate time being allowed for writing and receiving these discharge summaries. Although there are no plans for further follow-up, conducting a study with an extended time frame could be of value. Obstacles and possibilities for improving the transfer and use of discharge summaries need to be further explored. Could inadequate use be due to poor quality of the discharge summary? In addition, what information the Swedish GPs want in the discharge summary is not known, and further studies to explore their perceptions and experiences of the discharge summary could be of interest. Further, to examine whether a poorly updated medication list leads to medication errors and its possible consequences would be of value.