Background

Secretary of State for Health and Social Care, Jeremy Hunt, recently highlighted research which indicates that GPs, pharmacists, hospitals and care homes could be making up to 237 million medication errors a year – which is the equivalent of one mistake made for every five medicines administered. Researchers from the Universities of York, Manchester and Sheffield have reported that an estimated 712 deaths as a direct result of medication errors but claim errors could have been a contributory factor to between 1,700 and 22,303 deaths a year. In fact, in 2017 the World Health Organisation (WHO) confirmed that unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated at $42 billion USD annually[i]. WHO declared that ‘Medication Without Harm’ as the theme for the third Global Patient Safety Challenge.

Medication errors can occur at different stages of the medication use cycle and occur when weak medication systems and/or human factors such as fatigue, poor environmental conditions or staff shortages affect prescribing, transcribing, dispensing, administration and monitoring practices, which can then result in severe harm, disability and even death. Numerous studies, projects and interventions to address the frequency and impact of medication errors have already been developed, yet the implementation of any recommendations and learning is often varied and tends to be primarily focused on healthcare settings rather than social care settings.

In the history of the NHS, there has never been such a focus on improving the quality of health services and yet this is not necessarily the case in social care. Social care providers, including care homes, are required to have independent policies and procedures for medicines management including the identification and reporting of medication errors and yet the quality and implementation of such policies if often poor or absent.

Proposal

NICE guidance[ii] on medicines management in care homes clearly states that both ‘commissioners and providers of health or social care services should ensure that there are robust processes in place for identifying, reporting, reviewing and learning from medicines errors involving residents’. Implementation of this guidance recommendation varies nationally and this is evident form the Care Quality Commission (CQC) annual report ‘The state of adult social care services 2014 to 2017’ in which medicines management was a key factor associated with unsafe care. Specific issues included:

• Medicines not being administered properly
• Staff lacking knowledge of medicines and their side effects
• Issues with record keeping, including timeliness
• A lack of medicines audits
• Medicines being out of date and not being stored correctly

The primary aims of this project would be for health and social care staff to work collaboratively with care home providers, care home residents (and/or their representatives) to:

• create and implement a checklist/tool for care home staff to identify medicines safety risks/gaps and look at where medication safety improvements could be made
• provide training and good practice guidance for care staff on how to reduce medication errors
• introduce a number of interventions to improve reporting and reflection on medication errors and incidents
• create a list of simple checks/changes to practice for doctors to optimise safer prescribing of medicines for care home residents

Benefits

• Reducing harm caused from medication errors or improper use of medicines
• Reducing number of avoidable medicines related hospital admissions
• Improving quality of life and well-being for care home residents
• Empowering social care staff to improve quality of care through medicines safety
• Collaborative working and sharing of quality improvement models/practices with social care
• Improved collaborative working and understanding of medication risks and benefits
• Avoiding waste and costs associated with avoidable medicines related hospital admissions
• Promotes NHS values and objectives
• Supports the WHO third Global Patient Safety Challenge ‘Medication Without Harm’

Partners

• East Berkshire CCG
• East Berkshire care homes
• Oxford patient safety collaborative and Oxford AHSN network to provide guidance on governance and improvement methodology (TBC)
• Frimley Health NHS Foundation Trust
• Frimley Health and Care ICS Care homes quality governance group to support governance and implementation (TBC)
• Healthwatch (East Berkshire) (TBC)
• Berkshire Care Association (TBC)

References

[i] WHO Global Patient Safety Challenge: Medication Without Harm, 2017, [http://www.who.int/patientsafety/medication-safety/en/]

[ii] Managing medicines in care homes, NICE [SC1], March 2014, [https://www.nice.org.uk/guidance/sc1]