Research from the Royal Pharmaceutical Society1 on the transfer-of-care between settings has shown that when patients are transferred from one care setting to another between 30% and 70% of patients may have an unintentional change to their medicines. These unintentional changes, which may include dose changes, omitted drugs or incorrect drugs can cause patient harm, delay treatment and result in additional workload for a range of healthcare providers.
When patients are admitted to hospital, discharged or move house and start getting their medicines from a different community pharmacy, accurate and up-to-date medication history must be easily available to any pharmacy providing medicines and pharmaceutical care to those patients.
The process of medicines reconciliation on admission — ensuring that medicines prescribed on admission correspond to those that the patient was taking before admission — was the subject of a National Institute for Health and Care Excellence patient safety solution
2 published in December 2007. There is evidence from the University of Sheffield3
that medicines reconciliation is economically viable, saving between £5.52 and £13.64 per patient as a result of reduced length of stay and reduction in harm to patients. However, the safe transfer of pharmaceutical care is not just a one-way process into hospital.
IT solutions are being developed nationally and locally but the pace is not fast enough, coverage not wide enough and functionalities are lacking. NHS England announced on 29 August 2014 that five pilot areas (Somerset, Northampton, North Derbyshire, Sheffield and West Yorkshire) are to provide summary care record (SCR) access to 100 community pharmacies. However, SCRs only contain information about a patient’s previously prescribed medicines, allergies and any previous adverse reactions to medicines.
On the same day in August a patient safety alert4 was issued warning about risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care – including medicines which accounted for 13% of all discharge-associated moderate, low and no harm incidents captured in the National Reporting and Learning System. Shouldn’t there be a wider re-think about what is actually needed to join up what is described as the “golden thread” of pharmacy services across provision of safe and efficient seven-day services to NHS patients?
Nationally the SCR is providing some great improvements in access to information but only to some organisations and in some parts of the country. The last SCR bulletin identified that 37.5 million people have a record and that 63% or all surgeries are live and uploading records. SCR is helping improve the efficiency of medicines reconciliation and improving patient care. It is even helping to kill off the use of faxing in pharmacy – but it is not permitted to be a two-way process. It does not support the transfer of changes made in hospital to the GP, it does not capture discharge drugs supplied (or not), it does not allow community pharmacy to identify adherence issues, it does not allow the sharing of information on medicines only supplied by the hospital – including chemotherapy, anti-TNFs and other complex, high risk medicines that should be part of a complete patient record!
Local systems have been developed to try to expand on SCR functionality and support GP out-of-hours services, transfe- of-discharge information and, at last, fill in the missing link to support provision of this information to the group who have been missing up to now – the patients’ primary supplier of medicines – their community pharmacist. Portal systems, such as Bristol’s Connecting Care project, have the potential to join up social, primary, secondary and patient-led care.
As my starter for 10 a (near) perfect interoperable system would:
- Be available to any healthcare professional who needs to prescribe, administer or supply medicines 7 days a week at the time and the location that they are providing their service.
- Include information on all medication prescribed/supplied to the patient or stopped, including hospital-only products and homecare together with any adverse drug reactions seen.
- Allow for allergy information, including when and how the allergy manifests, to be added from all providers.
- Provide direct patient access to their own information to support adherence through enhanced patient friendly information and signposting to other support.
- Use standards for information including the dictionary of medicines and devices (dm+d), Royal College of Physicians standards for health and social care electronic records, NHS number and relevant security and data protection.
- Provide a secure method to communicate patient specific information and actions to relevant clinicians in different sectors without relying only on email – allowing continuity of information.
- Provide information on medication changes made while the patient was in hospital, and highlight this to the patients primary prescribers and pharmacy.
- Support referral to community pharmacy by hospital teams for New Medicines review and potential targeted MURs to support patients better in safely and effectively taking their medicines.
- Identify additional measures needed to support adherence such as the need for multi-compartment compliance aids, large type or additional counselling.
- Develop to include reporting tools for identification of clinical outcomes from prescribed medication, risk stratification for medicines in use by local patients, identification and reduction of waste and also key themes in relation to recurrent medicines issues where clinical practice variation may not align with the evidence base.
There needs to be an England-wide rethink about the way all our medicines-related IT systems work together across all sectors, perhaps with the formal development of pharmacy health informatics roles. This will not only improve patient safety but will support the transition from a supply-driven service to full patient-centred medicines optimisation that improves outcomes for all patients receiving medicines.
- Royal Pharmaceutical Society. (2011). Keeping patients safe when they transfer between care settings- Getting the medicines right. Royal Pharmaceutical Society.
- NICE. (2007). Technical patient safety solutions for medicines reconciliation on admission of adults to hospital .
- Karnon, C. C.-M. (2009). A systematic review of the effectiveness and cost-effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission. University of Sheffield.
- NHS England. (2014). Patient safety alert on risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care.