Date of Award


Document type


Degree Name

PhD (Doctor of Philosophy)

First Supervisor

Dr Catherine Duggan

Second Supervisor

Professor John Kelly


Drug Toxicity, Hospitals, Community.


Aims of the study

The aim of this thesis was to improve medication safety at the hospital community interface by generating a framework to identify the potential hazards in the current medication use process and devising a strategy to reduce them.


Mixed methods research was used. Healthcare record review was used to survey the potential hazards in the medication use process; interviews were used to obtain a broad perspective of the pharmacy workforce and services delivered at points around transfer of care and to explore the error vulnerabilities in the system and the attributes of the safety culture. The findings from all studies were integrated and triangulated to develop a framework to improve medication safety at points around transfer of care.


Medication non-reconciliation on discharge from acute and public hospital care was common (50% of inpatient episodes, 16% of medications) and had the potential to cause moderate to severe harm (65%) and medium to high potential to result in unplanned readmission to hospital (38%). Primary care practitioners perceived that the deficits in communication and reconciliation limited their ability to ensure the appropriate use of medication. Delivery of evidence based clinical pharmacy services on admission and discharge was identified in the survey of chief hospital pharmacists as rare (


Medication non-reconciliation is common and has the potential to cause patient harm. Strategies to improve patient safety should focus on advancing the medication safety culture, implementing system and process change. Future work should concentrate on development, implementation and evaluation of this strategy.

Creative Commons License

Creative Commons License
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A thesis submitted for the degree of Doctor of Philosophy from the Royal College of Surgeons in Ireland in 2009.