Seven ways practices can improve medicines’ safety

Providers across all health and care settings are working to ensure safe, high-quality care, often in challenging circumstances, says the CQC. But incidents involving medicines are common. To make sure that individual people receive their medicines safely, here the CQC offers seven ways practices can improve medicines’ safety

1. Pharmacy professionals play a vital role in improving the safe and effective use of medicines. We have seen the benefits to people when pharmacy staff are closely involved in services – either through face-to-face contact with patients or by strengthening systems by training staff and implementing technology. All types of health and care provider should consider how to include pharmacy staffing into the overall skill mix of their services. Providers need to find ways to work collaboratively with community pharmacies, which can act as partners to improve medicines’ safety. 

2. There is an immediate need to improve how medicines are managed when people are transferred between different health and care settings. Commissioners and providers of services need to work together to understand where there are local challenges in the system, improving communication and reducing risks to people at this important time. Care providers should have a systematic process to both receive and discharge people from their services, so that their medicines are managed safely and effectively; referring to summary care records could support this, with input from pharmacy professionals. 

3. It is essential to have appropriate policies and processes for all medicines-related activity. However, having a policy does not, in itself, change people’s behaviour. Policies need to be central to everyday practice, easy for staff to understand and readily accessible. They also need to be reviewed regularly to make sure they align with best practice guidance – including NICE guidance for medicines reconciliation – patient-centred care plans and accurate recording. 

4. Processes for reporting medicines incidents, and learning from them, need to be strengthened. Providers should make sure that staff know how to report incidents, including those that meet the threshold for reporting to CQC as statutory notifications. This involves promoting and encouraging a culture of safety and a ‘just culture’ approach to reporting incidents. Sharing learning from incidents across different organisations will help to raise awareness of risks as well as of actions which will help to mitigate them. 

5. Medicines for mental health conditions are sometimes managed poorly in acute hospital services; conversely, CQC found that people’s physical health is not always well looked after in mental health settings. More effective collaboration between providers can reduce disparity and improve people’s physical and mental health outcomes wherever they receive care. 

6. Local authorities and commissioners can provide leadership around medicines’ optimisation by working collaboratively with their providers. Holding regular forums with care providers can raise awareness of the importance of the safe and effective use of medicines. By collecting and sharing local knowledge and practice, and the challenges around medicines, joint action and improvement plans can be developed. 

7. Although not all providers currently have access to electronic systems for prescribing and/or administration, those that do should consider the best way to use these to support the safe use of medicines. For example, in mental health settings this could extend to linking information about prescribing and Mental Health Act requirements for a person, and provide better information to community teams administering people’s medicines. 

The information in this article comes from the CQC publication Medicines in health and adult social care, which you can access here. 

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