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The harm caused by medication errors has been recognised as a global issue, amid increasingly complex healthcare needs and the introduction of many new medicines.
The World Health Organisation (WHO) aims to halve the level of severe avoidable harm associated with medication error at any point in the process, that is, prescribing, dispensing, administration and monitoring, between 2017 and 2022.
National estimates published in the journal BMJ Quality & Safety indicate that more than 237 million medication errors are made every year in England, the avoidable consequences of which cost the NHS upwards of £98 million and more than 1,700 lives every year.
Their research found that medication errors are made at every stage of the process, with over half (54%) made at the point of administration, around 1 in 5 made during prescribing (21%), and 16% during dispensing.
Error rates are lowest in primary care, but because of the sector’s size, these account for nearly 4 out of every 10 (38%). Error rates are highest in care homes (42%), despite covering fewer patients than the other sectors. Around 1 in 5 medication errors are made in hospitals.
The researchers estimated that nearly 3 out of 4 medication errors (72%) are minor, while around 1 in 4 (just under 26%) have the potential to cause moderate harm; just 2% could potentially result in serious harm.
The safe and secure handling of medicines is the responsibility of every health and social care professional, who must ensure that they work within their professional guidelines.
Health and social care professionals are not only responsible for the safe delivery of medication but also upholding dignity, encouraging independence and respecting choices the service user/patient makes.
What is a medication manager?
Medication managers use their experience and knowledge of medicines to ensure that patients and service users get the medicines they need to effectively manage their condition.
They are equipped to offer advice on the correct storage and disposal of medicines, to advise about medication, any side effects, the correct dosage, and when and how it should be taken, ensuring patients and service users get the desired outcomes.
It is also their responsibility to ensure that giving or withholding medication should never be used as a means of control or punishment.
Medication managers uphold the rules of safe medicines management that are provided in National Institute for Health and Care Excellence (NICE) guidelines by ensuring that they observe the 6 R’s of safe medicines administration:
- Right person.
- Right medicine.
- Right route.
- Right dose.
- Right time.
- Right of the person to refuse.
Medication managers’ role in health and social care
In health and social care, it is important to remember at all times that no two patients are the same; some may have mobility issues, some chronic illness and others may need help with simple tasks that others take for granted. The same applies to the management of medicines.
Every patient has a different requirement, whether that means giving the patient medication occasionally to treat a minor illness or multiple pills every day to treat a chronic medical condition; it is important to handle those prescriptions the right way.
Medication management is broken down into five main areas:
- Administration of medication.
- Documentation, confidentiality and record keeping.
Medication managers must ensure that patients’ medicines are stored safely where children, pets and the curious cannot get at them. In a care home setting this is not a major problem as there will be designated areas for medication storage; however, in the case of domiciliary work where the patient’s home is visited, this is something that must be taken into account.
There will also be the need for special consideration if the patient has a mental illness or suffers from any kind of dementia; patients with dementia often get confused easily and may try to take medication at incorrect times.
The most common types of medicine are in tablet or pill form. Patients with complicated medical needs may require multiple medicines to be administered at different times of the day.
For home care workers it may be useful to speak to the NHS or the patient’s local pharmacist to see if they can provide what is known as a dosette box. Dosette boxes are storage containers with small compartments that clearly show which tablets need to be taken on which day.
Some are more advanced and allow pills to be spread out across a day and others can be securely locked to ensure only the carer can access them. If the patient lives at home, medicines should be kept in one place in the patient’s home, ideally a locked cupboard or drawer, especially if children live at or visit the property.
Attention also needs to be paid to the conditions in which the medicine is stored. Heat, air, light and moisture can damage medicines so they should always be stored in a cool, dry place.
A bathroom cabinet is not ideal as the heat and moisture from a shower, bath and sink can damage the medicines and medicines damaged in this way can become less potent or may go off before the expiration date. Capsules and pills are easily damaged by moisture and heat – Aspirin for example, breaks down into a vinegar and salicylic acid that can irritate the patient’s stomach.
The aim where possible should be to encourage as much independence for the patient in all aspects of their care, including dispensing medicine based on the individual’s health and care needs. Dispensing includes the preparation and transfer of medication to the end patient.
A risk assessment will need to be completed prior to dispensing any medicine to ensure that the patient receives the correct medication in the correct dosage at the right times. The risk assessment should also address risks to staff as well as the patient. Dosette boxes are a useful way of dispensing medication that has been prepared at an earlier date.
Any assessments must include the steps taken not only to ensure proper use but also confirming the pharmaceutical and therapeutic suitability of the medication for its intended use. Anyone responsible for the dispensing of medicine after consent must check that the product is acceptable for use. This includes examining pills and medicines for out of date products and organising replacements in advance.
The quality of the medicine also needs to be examined to ensure that it is suitable for immediate use.
The route of administration of medicine depends entirely on the requirement. Routes of administration are generally classified by the location on the body the medicine is applied. Common methods include oral, local (creams or lotions), inhalation and parenteral.
Parenteral administration includes intravenous, intramuscular, subcutaneous and intradermal administration. Some of these can be applied by a patient, or care worker, while others require administration by specialists. Examples of parenteral administration may include injections and catheterisation.
It is important to safely dispose of medicines when they are finished or out of date. When caring for a patient at home, old prescription medications should not be thrown away or flushed down the toilet. Discarding old prescription bottles amongst regular household waste could mean they end up in the wrong hands, harming people instead of helping them.
Flushing old pills down the toilet could contaminate the water supply or environment. Health and social care providers will have procedures in place for the correct disposal of medication, typically marked as clinical waste. Medicines for disposal should be stored securely in a tamper-proof container within a locked or out of reach cupboard until they are collected or returned to the pharmacy.
Documentation, confidentiality and record keeping
Health and social care providers should keep records of risk assessments, procedures and a list of all medicines on site, for both use and disposal. Records should include possible side effects and tie in with overall standard operating procedures in the event of an emergency.
Times of dispensing, dosage amount and other relevant notes for each patient need to be kept up to date to ensure risk is minimised. Any failure to follow correct practices can result in incidents that are harmful to the patient.
Records should include information about:
- Individual risk assessments.
- Obtaining or ordering controlled drugs.
- Supplying controlled drugs.
- Storing controlled drugs.
- Recording supply of controlled drugs to individuals.
- Reminding individuals to take their medicines (including controlled drugs).
- Disposal of unwanted controlled drugs.
Can anyone become a medication manager?
Patients rely on the medication prescribed by healthcare professionals to minimise pain and discomfort, alleviate or manage symptoms, and help them to live a more comfortable life. So effective medication management is vital to the performance of every health and social care organisation.
Although anyone working in health and social care can be responsible for managing medicines, inappropriate use or handling of these substances can have severe, or even fatal, consequences. For that reason, up-to-date knowledge of the safe handling of medicines is essential for anyone working with medication.
In addition, the Care Quality Commission (CQC) standards state that “staff responsible for medicines management and administration should be suitably trained and competent. They should work only within the scope of their qualifications, competence, skills and experience (including when administering medication).”
Medication training in health and social care
The CQC recommends that all staff dealing with medication receive induction training at the start of their employment.
Areas the training may cover include:
- Different forms of medication.
- Medication management legislation.
- Medication documentation and record keeping.
- Reporting and escalation procedures.
- Risks relating to medication management.
Those managing medication may need additional training to administer medicines using specialist techniques.
- Medicines applied to the skin.
- Inhalers and nebulised medicines.
- Oral syringes.
- Ear, nose and eye drops.
- Rectal or vaginal preparations.
- Buccal administration.
- Other medical devices such as hosiery devices.
- Subcutaneous injection.
- Administration of medicines via feeding tubes.
- Catheter care.
Identifying common types of medication
In a health and social care setting, it is likely that Controlled Drugs (CDs) will be used. CDs are prescribed medicines that are usually used to treat severe pain, induce anaesthesia or treat drug dependence, and they have additional safety precautions and requirements.
Some are also used in other situations, for example, methylphenidate (Ritalin™) is used in the treatment of attention deficit hyperactivity disorder (ADHD).
Examples of CDs are morphine, fentanyl and methylphenidate. CDs are prescribed and dispensed for individually named people, in the same way as other medicines. Some people abuse CDs by taking them when there is no clinical reason to do so.
There has been high profile given to managing CDs since the Shipman Inquiry published the fourth report in 2004, in which all social care services are recommended to have special arrangements for CDs even though the law does not currently require it.
Other types of medication will vary enormously depending upon the setting and patients or service users’ conditions.
Examples of commonly used medications may include:
- Medicated creams/ointments.
- Drops for ear, nose or eye.
- Diazepam (for epileptic seizure).
- Insulin (for diabetes).
- Levodopa, dopamine agonists or monoamine oxidase-B inhibitors (for Parkinson’s disease).
Deprescribing medication is the process of tapering, withdrawing, discontinuing or stopping medicines to reduce potentially problematic polypharmacy; that is, the use of multiple medications in a patient, adverse drug effects and inappropriate or ineffective medicine use.
It should be undertaken in the context of reviews for appropriate polypharmacy in partnership with the patient and sometimes their carer and supervised by a healthcare professional.
The Department for Health and Social Care describe deprescribing as “a collaborative process, with the patient and/or their carer, to ensure the safe and effective withdrawal of medicines that are no longer appropriate, beneficial or wanted, guided by a person-centred approach and shared decision-making.”
The aim of deprescribing medication is to:
- Improve quality of life.
- Avoid worsening of disease or causing withdrawal effects.
- Be effective in reducing pill burden.
- Maintain control of chronic conditions.
There is a five-step process that can be used when stopping medicines; this should be done initially as a trial:
- Gain a comprehensive medication history and check adherence. If a medicine is rarely or never taken this makes stopping easy, for example, patient states in the consultation they are not taking a particular medicine or if the medicine is administered the patient may continually spit out doses without swallowing.
- Identify any potentially inappropriate polypharmacy (PIP).
- Determine whether the PIP can be stopped.
- Plan the withdrawal regime – Reduce or stop one medicine at a time. If problems develop it makes it easier to identify the likely cause. Consider if the medicine can be stopped abruptly, for example if toxicity has developed, or needs to be tapered, this is usually the best option; sometimes a smaller dose may need to be continued long term.
- Check for benefit or harm after each medicine has been reduced or stopped, and provide contact details to the patient for support in case of problems. This may include monitoring tests.
Deprescribing must be done carefully, with monitoring, to avoid worsening of disease or causing withdrawal effects. People who use health and social care services should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals and social care practitioners.
It is recognised that deprescribing is a complex process, not a single act, involving multiple steps.
There are different approaches to stopping medicines that may be employed:
- Stepwise approach – Useful if the patient is well and clinically stable but there is a risk that multiple changes in drugs will destabilise their situation. Tapering the dose helps reduce the likelihood of an adverse withdrawal event for some medicines.
- All at once – Useful if the patient is unwell as a result of likely drug side effects or in a safe monitored environment, for example an admission to hospital.
- Mixed approach – In practice, often several drugs can be stopped or reduced at once with little chance of harm. However, certain drugs, for example antidepressant and antipsychotic drugs, will need to be withdrawn more cautiously. In these situations, it should be documented clearly which drugs can be stopped immediately and which drugs are to be withdrawn more cautiously.
The Royal Pharmaceutical Society publishes a variety of deprescribing medication guidelines for care professionals.
Medication management guidelines to follow
Irrespective of the type of service being run, it is the responsibility of all care providers to apply the highest standards of safety to medication management. All care services are expected to ensure that medicines are received, handled, stored, administered, disposed of and recorded in accordance with statutory and regulatory requirements, as well as best practice recommendations.
Legislation and regulations that govern medication management include:
- The Medicines Act 1968.
- The Misuse of Drugs Act 1971.
- The Misuse of Drugs (Safe Custody) Regulations 1973.
- Human Medicines Regulations 2012.
- Care Standards Act 2000.
- Care Act 2014.
- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
- The Mental Capacity Act 2005.
- SC1 Managing Medicines in Care Homes (March 2014), National Institute for Health and Care Excellence (NICE).
- NG11 Challenging Behaviour and Learning Disabilities: Prevention and Interventions for People with Learning Disabilities Whose Behaviour Challenges (May 2015), National Institute for Health and Care Excellence (NICE).
- QS85 Medicines Management in Care Homes (March 2015), National Institute for Health and Care Excellence (NICE).
- Improving patient outcomes – the better use of multi-compartment compliance aids (July 2013), Royal Pharmaceutical Society.
- The Safe and Secure Handling of Medicines (December 2018), Royal Pharmaceutical Society.
When social care providers are responsible for medicines support, they must have robust processes for medicines-related safeguarding incidents, in line with Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Nurses should follow the Nursing and Midwifery Council professional standards of practice and behaviour.
Errors can occur at different stages of the medication use process. Medicines errors are not the same as adverse drug reactions.
A medicines error is any patient safety incident where there has been an error while:
- Providing advice on medicines.
NICE guidance on managing medicines in care homes (SC1) states that care home providers “should ensure that a robust process is in place for identifying, reporting, reviewing and learning from medicines errors involving residents.”
NICE guidance for adults receiving social care in the community (NG67) states that “When social care providers have responsibilities for medicines support, they should have robust processes for identifying, reporting, reviewing and learning from medicines-related problems.”
If there is a safety incident, care providers should check Regulation 20 to see if it is a notifiable safety incident. If it is, the regulation explains how the relevant people must be supported; they could be people who use services or people acting on their behalf.
Care providers must:
- Act in an open and transparent way with relevant persons about the care and treatment provided.
- Tell them in person as soon as possible after finding out about the incident. Support them around the incident, including when you tell them what happened.
- Provide an accurate account of what happened. This must include all the facts, to the best of your knowledge, at the time.
- Tell them in person what further enquiries you will need to make.
- Offer an apology in person.
- Follow this by giving the same information in writing. Give an update on the enquiries.
- Keep a written record of all communication with the relevant person.
There is no requirement to notify the Care Quality Commission (CQC) about medicines errors, but they must be informed if a medicines error has caused:
- A death.
- An injury.
- Abuse, or an allegation of abuse.
- An incident reported to or investigated by the police.
Where relevant, care providers should make it clear that a medicine error was a known or possible cause or effect of these incidents or events being notified.
Health and social care providers should also comply with relevant Patient Safety Alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and via the Central Alerting System (CAS).