{
  "abstract": "Introduction Discharge from hospital is a high-risk transition, particularly for paediatric patients, where medicines may be unlicensed, involve weight-based dosing, or require brand-specific formulations. These factors demand precise communication around dose, strength, formulation, supply, and follow-up to ensure safe continuity of care. However, variation in discharge processes and documentation is widespread, and failures in communication have resulted in serious harm. 1 In 2020, a baby died after being given a twentyfold overdose of morphine due to conflicting dose instructions and a lack of clarity about the formulation and volume to administer.2 The Coroner’s Regulation 28 report concluded that both prescribing and dispensing errors contributed to her death and called for national action to improve paediatric medicines communication.2 In response to these concerns, the Royal College of Paediatrics and Child Health (RCPCH) and the Neonatal and Paediatric Pharmacists Group (NPPG) Joint Medicines Committee conducted a UK-wide survey of healthcare professionals involved in paediatric discharge. The aim was to gather national insight into current discharge practices, identify variation in the quality of medicines information provided to primary care, and explore opportunities to improve safety and consistency for children and young people.Methods The survey was disseminated via the NPPG mailing list and the RCPCH website. Quantitative data were summarised using descriptive statistics, and qualitative free-text responses were thematically analysed. The survey explored the use of electronic prescribing systems (EPS), clarity of discharge information, communication of unlicensed and special medicines, pharmacist involvement, and continuity of supply following discharge.Results A total of 127 responses were received from 103 healthcare organisations across the UK, with pharmacists comprising the majority of respondents (n=101). Most organisations used Cerner or EPIC as their EPS. Only 8% (10/127) of respondents reported that unlicensed or special medicines were consistently identified in discharge summaries, while 9% (12/127) indicated that brand requirements were routinely documented.The strength of oral liquids was clearly stated in 51% (65/127) of responses (referring to oral all liquids, not just unlicensed), though variation in dose formats was commonly reported. Only 19% of respondents (24/127) reported that discharge summaries consistently specified where the next supply should be obtained. Information about treatment duration, review timelines, and follow-up prescribing responsibility was often missing. Pharmacist involvement was seen to improve clarity, although out-of-hours cover remained limited.Discussion This survey highlights significant variation and avoidable risks in paediatric discharge communication across the UK. Responses suggest inconsistencies in how electronic systems capture critical information, with some reliance on free-text entries, which may contribute to inconsistency. Standardised discharge templates, enhanced EPS functionality, and routine paediatric pharmacist involvement are urgently required. While some organisations have adopted improvements such as embedding QR codes to Medicines for Children resources or implementing the Discharge Medicines Service, uptake remains inconsistent. Improving the quality of discharge communication is essential to reducing harm and safeguarding paediatric patients.References Royal Pharmaceutical Society. Keeping patients safe when they transfer between care providers: getting the medicines right. Royal Pharmaceutical Society 2012. Available from: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Publications/Keeping%20patients%20safe%20transfer%20of%20care%20report.pdf HM Coroner. Juanita Nti: Prevention of Future Deaths report. London: Courts and Tribunals Judiciary 2020. Available from: https://www.judiciary.uk/prevention-of-future-death-reports/juanita-nti-prevention-of-future-deaths-report/",
  "authors": [
    {
      "affiliations": [
        "Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, UK"
      ],
      "name": "Ashifa Trivedi"
    },
    {
      "affiliations": [
        "Great Ormond Street Hospital, UK"
      ],
      "name": "Stephen Tomlin"
    }
  ],
  "title": "P02 Improving paediatric medicine discharge communication: a national survey",
  "uid": "e45c705e-2976-5495-89bc-3c16f17ee145"
}