Date Published: 27 October 2009

NHS must do more to prevent harm to patients from prescribed medicines after leaving hospital, say CQC

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 has publishes findings from its study of how well patients' medication is managed after leaving hospital. It visited 12 primary care trusts (PCTs), as commissioners of GP and hospital care, and surveyed 280 of their GP practices.

There are risks to the safety of patients when they are prescribed medicines, particularly after leaving hospital. 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.

During its visits, the CQC saw some evidence of 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.

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.

CQC, which is championing joined-up services across the health and adult social care system, found overall that GP practices have good repeat prescribing systems in place to reduce risks associated with patients taking medication for longer than necessary, particularly if their medication changed while in hospital.

It also found patients taking high-risk medicines, such as treatment for blood clots, generally have their medication reviewed by a GP soon after discharge from hospital to spot potential problems and discuss any side-effects of newly prescribed drugs.

But 81% of GP practices surveyed said 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, known as co-morbidities (14%); or known allergies (11%), when patients are admitted. This means hospitals could prescribe medicines that are harmful.

Cynthia Bower, CQC's Chief Executive, said:

" We know that incidents related to medication can cause people significant problems and sometimes unnecessary harm and distress.

Not all adverse drug reactions are preventable, but the potential risks are clear. It is important that basic systems to share essential patient details are working effectively to get the right information to clinicians at the right time to minimise these risks. It is clear from this study that services have some way to go before this routinely happens in the way it should.

People have a right to expect clinicians to know details about each stage of their care, and in this day and age they are right to do so. It's not possible for a clinician to make good decisions about care unless they have key information about a patient.

There needs to be a change of attitude in the NHS in recognising how important it is for clinicians to pass the baton smoothly between services in order to offer person-centred, integrated care. ”

The CQC's study highlights several areas needing improvement. It found that:

• Information shared between GPs and hospitals when a patient moves between services is often patchy, incomplete and not shared quickly enough.
• Updating of GP patient records is not always carried out by clinical staff.
• Too few patients are offered discussions with their GP about managing their medication.
• GPs are not consistently reporting medication incidents and errors, and PCTs are not always monitoring them.

The CQC says the safety of medicines management cannot be improved if incidents and errors are not reported, and lessons learned from them. It recommends GPs should do more to capture, record and report instances to PCTs and the NPSA. PCTs should also better monitor GP practice performance in this area.

The CQC has shared its recommendations with the PCTs involved in the study, to implement the necessary improvements. It also encourages the wider NHS to learn from these findings and check that their own systems to manage medicines are sufficient to protect patients from potential harm.

The regulator will be looking at clinical governance in PCTs as progress is made towards the registration of primary care. In addition, CQC will consider how it will continue to lever improvement when the reviews it undertakes uncover poor practice.

About the CareQuality Commission: The Care Quality Commission (CQC) is the independent regulator of all health and adult social care in England. The CareQuality Commission inspects health and adult social care services in England, whether they're provided by the NHS, local authorities, private companies or voluntary organisations. It also protects the interests of people detained under the Mental Health Act. (Until 31 March 2009, this work was carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection.)

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