Section 1: Safe Management and Use of Medicines

Safe management and use of medicines is essential to ensure that patients derive the maximum benefit from treatment and are not put at risk of avoidable side-effects or medication errors. Poor management of medicines leads to increased morbidity, poor quality of life and poor health outcomes. Moreover, poor management of medicines also has cost implications due to wasted medicines resulting from poor adherence or inappropriate prescribing.

Patient safety in relation to medicines is central to any pharmaceutical service. There is general agreement that the majority of medication errors occur because of system errors, in particular, latent errors. “Latent” errors are things that could go wrong but do not because most of the time they are filtered out at a later stage. For example, a dosage instruction for a medicine could be absent or ambiguously recorded but experienced staff give the correct dose because they know the medicine and the individual involved. When a different member of staff (who is unfamiliar with the situation) is responsible for giving the medicine, he or she can only work with the available documentation and an incorrect dose could be given or a dose could be omitted. This is often described as the “Swiss cheese” model, where a management system is envisaged as slices of Swiss cheese. There are holes at each slice but usually the holes do not line up to provide a clear route through all the layers. Occasionally, the holes do line up and an error can go all the way through the system without being intercepted.

The National Patient Safety Agency has issued extensive guidance for safe management of medicines (e.g. Improving compliance with methotrexate guidelines, NPSA 2006/13; Actions that can make anticoagulant therapy safer, NPSA 2007/18); however, reports continue to show that this is a major issue.

In 2006 the Commission for Social Care Inspection reported that some care homes were failing to manage medicines properly and had improved little over the previous two years. The report noted that common complaints were:

  • The wrong drug was administered, or too much or too little of the medicine medication was given;
  • Medicines were missed, or were given too late or too early;
  • Staff administering medicines were not adequately trained;
  • Medicines were left unattended in a communal place, or was lost;
  • Running out of stock of a particular type of medicine, or being overstocked;
  • Mistakes in records of medicine administration.

In 2009, the findings of the Care Homes Use of Medicines study (CHUMS), which measured the prevalence of medication errors (prescribing, monitoring, dispensing, administering and interface) in nursing and residential homes showed that 70% of care home residents were exposed to one or more medication errors. The investigators noted that many of the errors would reduce the resident’s quality of life and ability to function. They considered that a major hurdle to effective management and use of medicines in these settings is that under the current arrangements no one has overall ownership or responsibility for the system. Consequently, the needs of a particularly frail and vulnerable group of patients are not always effectively addressed. The authors recommended that a pharmacist should have overall responsibility for the use of medicines in a care home or a group of homes in order to improve medicines safety.

One UK study showed that:

  • 6.5% of hospital admissions were related to adverse drug reactions.
  • The median hospital stay was eight days
  • The projected annual cost of such admissions for the NHS was £466M (at 2004 prices) 
Most of the adverse drug reactions involved were considered to be avoidable.¹

In addition, two recent reports further underline the need for high quality medicines management in care homes.

A report entitled, Working together to prevent and control infections: A study of the arrangements for infection prevention and control between hospitals and care homes, found that infection control was often poorly managed and that staff lacked suitable training.  

An independent report, The use of antipsychotic medication for people with dementia:Time for action, concluded that only 36,000 of the 180,000 people currently receiving antipsychotic treatment for dementia are likely to benefit from it and it is likely to cause an additional 1,800 deaths, and an additional 1,620 cerebrovascular adverse events per annum. One of the report’s recommendations was that regular input from a pharmacist should be available. 

Reports have called for better management of medicines in social care settings and have specifically identified the role of primary care services. The recent white paper, Pharmacy in England: Building on strengths – delivering the future, outlines a vision for improved quality and effectiveness of pharmaceutical services and a wider contribution to public health.  It states that, ‘The Government considers that chief pharmacists of provider organisations, PCTs and other commissioners should have a lead role in ensuring that safe medication practices are embedded in patient care.’ (Pharmacy in England 2008 para 3.80).

Until recently there has been little formal, published information about the use of medicines in social care settings and much of our understanding of this area was derived from the report, Handled with Care, feedback from pharmacist inspectors working for social care regulatory bodies in the three countries and from other pharmacists working in primary care. However, the recent reports described above provide clear evidence of the shortcomings in this field and the impact that this is having on a group of frail and vulnerable people.

¹Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, Farrar K, Park BK, Breckenridge AM. BMJ  2004;329:15-19