The NHS may be at risk of failing to prevent harm to patients from medicines unless it improves sharing of vital information when people move between services, according to the Care Quality Commission (CQC). The regulator recently assessed how well patients’ medication is being managed after leaving hospital and found that there were serious issues.
Incidents involving medication, such as prescribing errors and failures to review medication after discharge, were the fourth most commonly reported to the National Patient Safety Agency during 2008. One study estimates around 4% of all hospital admissions are due to preventable medicine-related issues.
Following visits to 12 primary care Trusts (PCTs) and a survey of 280 GP practices, the CQC reported evidence of some good practice, but also found the following concerns: GP practices and hospitals do not always share timely, complete patient information on medication changes when people move between services; reviewing and updating of GP records is sometimes left to administrative staff; GPs do not routinely review new medication with a patient after they leave hospital; and monitoring and learning from serious incidents is patchy.
Some 81% of GP practices said that, when hospitals sent them summaries of the care they had provided to patients, details of medicines prescribed were incomplete or inaccurate "all of the time" or "most of the time". This is particularly concerning as a GP may subsequently prescribe incompatible drugs, which may lead to harm.
The CQC also found some practices were not systematically providing hospitals with information on: previous drug reactions (24%); other existing illnesses (14%); or known allergies (11%), when patients are admitted. This means hospitals could prescribe medicines that are harmful.
From April 2010, all Trusts will be required by law to register with CQC and must meet a new set of standards. Effective management of medicines will be a requirement of registration, and CQC will take action where Trusts fall short of meeting this. The regulator therefore urges all Trusts and GP practices to use the findings of its study to identify problem areas in preparation for registration.
