By Dr Jill Loader, Deputy Director Pharmacy Commissioning (England), NHS England
Since the NHS was established 75 years ago, community pharmacy is playing a greater role than ever in providing new integrated clinical services and helping local communities to improve their health and well-being.
Throughout these changes, patient safety has always been an integral part of the activity that takes place in every community pharmacy; whether it’s reviewing a discharge medicines summary for a patient recently discharged from hospital, to check they understand what medicines to take, explaining how to take a newly prescribed medicine for the first time, or helping people to understand how, and in what order, to use their inhalers.
Medication errors are one of the biggest causes of avoidable harm to patients. Medication Without Harm, the World Health Organisation’s Global Patient Safety Challenge was launched in 2017, aiming to reduce severe and avoidable medication-related harm by 50% over five years. And in response, as part of the NHS Long Term Plan, NHS England introduced the Medicines Safety Improvement Programme.
Community pharmacy teams have been playing a vital role in delivering this programme and since 2018, as part of the Pharmacy Quality Scheme (PQS) safety audits, 600,000 patients taking some of the most high-risk medicines have been identified, with almost 9,000 pharmacies taking part.
The audits undertaken have covered a number of high-risk areas including preventing harm to unborn babies from valproate, using non-steroidal anti-inflammatory drugs (NSAIDs) safely in older people more prone to side effects, the safe use of oral anticoagulants and antimicrobial stewardship initiatives.
Across the audits of different medicines, clinical advice was provided to patients 385,000 times, to help improve medicines safety, such as the need for a blood test to confirm the correct dose, or advice about managing an interacting medicine to prevent side effects.
Pharmacy teams also identified 90,000 people who were at sufficient risk to require further referral to their GP or other prescribers, for example, to consider symptoms of toxicity reported by the patient, to prescribe another medicine such as gastroprotection to prevent harm when taking an NSAID, or to consider stopping a potentially contraindicated medicine.
The audits also found that:
- almost a quarter of patients taking anticoagulants couldn’t describe the symptoms of over-anticoagulation and were provided with advice by the pharmacy teams on what to look out for;
- 34% of patients taking lithium for mental health disorders and 30% of patients taking amiodarone for heart rhythm disorders could not describe the signs of toxicity and were advised what to look out for by pharmacy teams;
- for NSAIDs in older patients, recommendations, and changes to improve safety and reduce harm following one audit cycle were shown to have been embedded into practice following a second audit cycle. The number of patients without gastroprotection referred to the prescriber increased from 59% to 68% and the number of patients co-prescribed a gastroprotective agent increased from 81% to 85%.
Antimicrobial resistance is a global health emergency and pharmacy teams are also supporting stewardship of antimicrobials using the TARGET resources. These are available in many languages and are designed to start conversations about the need for antibiotics, when an antibiotic is indicated, and how to manage symptoms of common infections. Pharmacy teams explain to patients the benefits of preventing infections and support the increased uptake of vaccinations.
Community pharmacy teams are uniquely placed to continue to support patient and medicines safety-related activities. The findings from the audits show there is scope across the healthcare system to improve the understanding of patients who are prescribed high-risk medicines, so they understand the warning signs to look out for and how to minimise risks. The audit report recommends that multidisciplinary teams work together to improve counselling and shared decision-making and increase medicine safety for patients.
The latest Pharmacy Quality Scheme 2023/24 launched on 1 June 2023, builds on this previous safety activity with specific criteria around antimicrobial stewardship activities and a re-audit of oral anticoagulants, encouraging pharmacy teams to implement the findings and recommendations from the 2021/22 audit into their day to day practice. It also includes criteria to ensure patients can access the end-of-life medicines they need, which the RPS Daffodil Standards on palliative and end-of-life care, complement.
This will help continue the important work to improve patient safety, reduce potential harm and health inequalities and improve the quality of life for patients, and I congratulate community pharmacy teams for their hard work, on this NHS 75th birthday!
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The reports and audit tools referred to can be accessed at NHS England » Pharmacy quality scheme and the following papers have been published on this work