A new report published today by the Royal Pharmaceutical Society calls for improvements to the transfer of information about medicines when patients move between care settings.

Keeping patients safe when they transfer between care providers: Getting the medicines right outlines the results of a six-month project involving over 30 healthcare organisations which volunteered to implement RPS guidance on transfer of medicines information.  The guidance was endorsed by the Royal College of General Practitioners, the Royal College of Nursing, the Royal College of Physicians and the Academy of Medical Royal Colleges and had a joint foreward from the Medical Director of the NHS, the Chief Nursing Officer and the Chief Pharmaceutical Officer.

The likelihood that an elderly medical patient will be discharged on the same medicines that they were admitted on is less than 10%^[1]. Between 28-40% of medicines are discontinued during hospitalisation^[2] and 45% of medicines prescribed at discharge are new medicines^[3]. Around 60% of patients have 3 or more medicines changed during their hospital stay^[4] and adverse drug events occur in up to 20% of patients after discharge.

“Getting the transfer of medicines information right can be challenging as patients follow complex pathways and systems vary between providers.  However, it’s totally unacceptable that poor transfer of medicines information continues to compromise patient care” said RPS Policy and Practice Lead Heidi Wright.

“Strategies must improve and the experiences of the volunteer sites in driving change in their organisations have created a set of recommendations which should be adopted across the NHS”.

The recommendations of the report are:

• All suppliers of IT systems to hospitals and general practice should ensure their systems can effectively transfer recommended core content of medicines records
• All community pharmacies should have an NHS.net website address to enable secure communications between secondary and primary care
• All clinical records should be structured in a recognised and nationally agreed format to assist interoperability and the transfer of information
• National sharing of the most effective ways of signposting patients in secondary care to the post discharge Medicine Review Service and New Medicine Service provided by community pharmacists to enable patients to optimise benefits from their medicines
• Commissioning of post-discharge MURs for vulnerable patients should be considered as part of the pharmacy contractual frameworks

Projects included improving medicines reconciliation procedures, driving up standards of discharge information and focussing on communication with patients, for example through patient held medication records or ‘green bag’ schemes, where patients’ medicines are collated into a reusable green bag prior to admission or post-discharge.

The sites worked with front-line staff, clinicians, patients and managers and encompassed a wide variety of care settings such as hospitals, care homes and sheltered housing.  They were supported by a virtual faculty of experts and peer support through structured workshops provided by the Society. 

“It’s great that so much progress has been made on the ground in such a short time,” said Heidi.  “Reducing avoidable harm and medicines related admissions to hospital remains paramount.  The challenge now is to keep the momentum going to drive improvements locally and ensure that patient safety risks are addressed on a national level”.

Ends

For media enquiries please contact the Royal Pharmaceutical Society's media team on 020 7572 2653 or out of hours 07860 643862.

Notes to Editors:

The NHS Litigation Authority has included reference to the guidance as a pilot standard in their medicines management requirements.

There will also be a standard on transfer of medicines information in the new RPS Professional Standards for Hospital Pharmacy Services, as one of the ten standards that underpin quality pharmacy services.  This guidance will be published in July 2012.

[1] Relationship of in-hospital medication modifications of elderly patients to post discharge medications, adherence and mortality. Ann Pharmacotherapy 2008; 42: 783-9
[2] Health care system vulnerabilities: understanding the root causes of patient harm. Am J Health Syst Pharm 2012; 69: 43-5
[3] What happens to long-term medication when general practice patients are referred to hospital? Eur J Clin Pharmacol 1996; 50: 253-7
[4] Drug changes at the interface between primary and secondary care. Int J Clin Pharmacol Ther. 2004; 42:103-9