Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes

Organisations should support a person‑centred, 'fair blame' culture that encourages reporting and learning from medicines‑related patient safety incidents.

Health and social care practitioners should explain to patients, and their family members or carers where appropriate, how to identify and report medicines‑related patient safety incidents.

Organisations should ensure that robust and transparent processes are in place to identify, report, prioritise, investigate and learn from medicines‑related patient safety incidents, in line with national patient safety reporting systems – for example, the National Reporting and Learning System.

Organisations should consider using multiple methods to identify medicines‑related patient safety incidents – for example, health record review, patient surveys and direct observation of medicines administration. They should agree the approach locally and review arrangements regularly to reflect local and national learning.

Organisations should ensure that national medicines safety guidance, such as patient safety alerts, are actioned within a specified or locally agreed timeframe.

Organisations should consider assessing the training and education needs of health and social care practitioners to help patients and practitioners to identify and report medicines‑related patient safety incidents.

Health and social care practitioners should report all identified medicines‑related patient safety incidents consistently and in a timely manner, in line with local and national patient safety reporting systems, to ensure that patient safety is not compromised.

Organisations and health professionals should consider applying the principles of the PINCER intervention to reduce the number of medicines‑related patient safety incidents, taking account of existing systems and resource implications. These principles include:

• using information technology support

• using educational outreach with regular reinforcement of educational messages

• actively involving a multidisciplinary team, including GPs, nurses and support staff

• having dedicated pharmacist support

• agreeing an action plan with clear objectives

• providing regular feedback on progress

• providing clear, concise, evidence‑based information.

Consider using a screening tool – for example, the STOPP/START tool in older people – to identify potential medicines‑related patient safety incidents in some groups (STOPP, Screening Tool of Older Persons' potentially inappropriate Prescriptions; START, Screening Tool to Alert to Right Treatment). These groups may include:

• adults, children and young people taking multiple medicines (polypharmacy)

• adults, children and young people with chronic or long‑term conditions

• older people.

Organisations should consider exploring what barriers exist that may reduce reporting and learning from medicines‑related patient safety incidents. Any barriers identified should be addressed – for example, using a documented action plan.

Health and social care organisations and practitioners should:

• ensure that action is taken to reduce further risk when medicines‑related patient safety incidents are identified

• apply and share learning in the organisation and across the local health economy, including feedback on trends or significant incidents to support continuing professional development. This may be through a medicines safety officer, controlled drugs accountable officer or other medicines safety lead.

Organisations should ensure that robust and transparent processes are in place, so that when a person is transferred from one care setting to another:

• the current care provider shares complete and accurate information about the person's medicines with the new care provider and

• the new care provider receives and documents this information, and acts on it.
  
  Organisational and individual roles and responsibilities should be clearly defined. Regularly review and monitor the effectiveness of these processes. See also section 1.3 on medicines reconciliation.
  
  Take into account the 5 rules set out in the Health and Social Care Information Centre's guide to confidentiality in health and social care when sharing information.

For all care settings, health and social care practitioners should proactively share complete and accurate information about medicines:

• ideally within 24 hours of the person being transferred, to ensure that patient safety is not compromised and

• in the most effective and secure way, such as by secure electronic communication, recognising that more than one approach may be needed.

Health and social care practitioners should share relevant information about the person and their medicines when a person transfers from one care setting to another. This should include, but is not limited to, all of the following:

• contact details of the person and their GP

• details of other relevant contacts identified by the person and their family members or carers where appropriate – for example, their nominated community pharmacy

• known drug allergies and reactions to medicines or their ingredients, and the type of reaction experienced (see NICE's guideline on drug allergy)

• details of the medicines the person is currently taking (including prescribed, over-the-counter and complementary medicines) – name, strength, form, dose, timing, frequency and duration, how the medicines are taken and what they are being taken for

• changes to medicines, including medicines started or stopped, or dosage changes, and reason for the change

• date and time of the last dose, such as for weekly or monthly medicines, including injections

• what information has been given to the person, and their family members or carers where appropriate

• any other information needed – for example, when the medicines should be reviewed, ongoing monitoring needs and any support the person needs to carry on taking the medicines. Additional information may be needed for specific groups of people, such as children.

Health and social care practitioners should discuss relevant information about medicines with the person, and their family members or carers where appropriate, at the time of transfer. They should give the person, and their family members or carers where appropriate, a complete and accurate list of their medicines in a format that is suitable for them. This should include all current medicines and any changes to medicines made during their stay.

Consider sending a person's medicines discharge information to their nominated community pharmacy, when possible and in agreement with the person.

Organisations should consider arranging additional support for some groups of people when they have been discharged from hospital, such as pharmacist counselling, telephone follow‑up, and GP or nurse follow‑up home visits. These groups may include:

• adults, children and young people taking multiple medicines (polypharmacy)

• adults, children and young people with chronic or long‑term conditions

• older people.

In an acute setting, accurately list all of the person's medicines (including prescribed, over‑the‑counter and complementary medicines) and carry out medicines reconciliation within 24 hours or sooner if clinically necessary, when the person moves from one care setting to another – for example, if they are admitted to hospital.

Recognise that medicines reconciliation may need to be carried out on more than one occasion during a hospital stay – for example, when the person is admitted, transferred between wards or discharged.

In primary care, carry out medicines reconciliation for all people who have been discharged from hospital or another care setting. This should happen as soon as is practically possible, before a prescription or new supply of medicines is issued and within 1 week of the GP practice receiving the information.

In all care settings organisations should ensure that a designated health professional has overall organisational responsibility for the medicines reconciliation process. The process should be determined locally and include:

• organisational responsibilities

• responsibilities of health and social care practitioners involved in the process (including who they are accountable to)

• individual training and competency needs.

Organisations should ensure that medicines reconciliation is carried out by a trained and competent health professional – ideally a pharmacist, pharmacy technician, nurse or doctor – with the necessary knowledge, skills and expertise including:

• effective communication skills

• technical knowledge of processes for managing medicines

• therapeutic knowledge of medicines use.

Involve patients and their family members or carers, where appropriate, in the medicines reconciliation process.

When carrying out medicines reconciliation, record relevant information on an electronic or paper‑based form. See section 1.2 on medicines‑related communication systems.

Consider carrying out a structured medication review for some groups of people when a clear purpose for the review has been identified. These groups may include:

• adults, children and young people taking multiple medicines (polypharmacy)

• adults, children and young people with chronic or long‑term conditions

• older people.

Organisations should determine locally the most appropriate health professional to carry out a structured medication review, based on their knowledge and skills, including all of the following:

• technical knowledge of processes for managing medicines

• therapeutic knowledge on medicines use

• effective communication skills.
  
  The medication review may be led, for example, by a pharmacist or by an appropriate health professional who is part of a multidisciplinary team.

During a structured medication review, take into account:

• the person's, and their family members or carers where appropriate, views and understanding about their medicines

• the person's, and their family members' or carers' where appropriate, concerns, questions or problems with the medicines

• all prescribed, over-the-counter and complementary medicines that the person is taking or using, and what these are for

• how safe the medicines are, how well they work for the person, how appropriate they are, and whether their use is in line with national guidance

• whether the person has had or has any risk factors for developing adverse drug reactions (report adverse drug reactions in line with the yellow card scheme)

• any monitoring that is needed.

When discussing medicines with people who have chronic or long‑term conditions, consider using an individualised, documented self‑management plan to support people who want to be involved in managing their medicines. Discuss at least all of the following:

• the person's knowledge and skills needed to use the plan, using a risk assessment if needed

• the benefits and risks of using the plan

• the person's values and preferences

• how to use the plan

• any support, signposting or monitoring the person needs.
  
  Record the discussion in the person's medical notes or care plan as appropriate.

When developing an individualised, documented self‑management plan, provide it in an accessible format for the person and consider including:

• the plan's start and review dates

• the conditions being managed

• a description of medicines being taken under the plan (including the timing)

• a list of the medicines that may be self‑administered under the plan and their permitted frequency of use, including any strength or dose restrictions and how long a medicine may be taken for

• known drug allergies and reactions to medicines or their ingredients, and the type of reaction experienced (see the NICE guideline on drug allergy)

• arrangements for the person to report suspected or known adverse reactions to medicines

• circumstances in which the person should refer to, or seek advice from, a health professional

• the individual responsibilities of the health professional and the person

• any other instructions the person needs to safely and effectively self‑manage their medicines.

Review the self‑management plan to ensure the person does not have problems using it.

Offer all people the opportunity to be involved in making decisions about their medicines. Find out what level of involvement in decision‑making the person would like and avoid making assumptions about this.

Find out about a person's values and preferences by discussing what is important to them about managing their conditions and their medicines. Recognise that the person's values and preferences may be different from those of the health professional and avoid making assumptions about these.

Apply the principles of evidence‑based medicine when discussing the available treatment options with a person in a consultation about medicines. Use the best available evidence when making decisions with or for individuals, together with clinical expertise and the person's values and preferences.

In a consultation about medicines, offer the person, and their family members or carers where appropriate, the opportunity to use a patient decision aid (when one is available) to help them make a preference-sensitive decision that involves trade‑offs between benefits and harms. Ensure the patient decision aid is appropriate in the context of the consultation as a whole.

Do not use a patient decision aid to replace discussions with a person in a consultation about medicines.

Recognise that it may be appropriate to have more than one consultation to ensure that a person can make an informed decision about their medicines. Give the person the opportunity to review their decision, because this may change over time – for example, a person's baseline risk may change.

Ensure that patient decision aids used in consultations about medicines have followed a robust and transparent development process, in line with NICE's Standards framework for shared-decision-making support tools, including patient decision aids or the International Patient Decision Aid Standards criteria.

Before using a patient decision aid with a person in a consultation about medicines, read and understand its content, paying particular attention to its limitations and the need to adjust discussions according to the person's baseline risk.

Ensure that the necessary knowledge, skills and expertise have been obtained before using a patient decision aid. This includes:

• relevant clinical knowledge

• effective communication and consultation skills, especially when finding out patients' values and preferences

• effective numeracy skills, especially when explaining the benefits and harms in natural frequencies, and relative and absolute risk

• explaining the trade‑offs between particular benefits and harms.

Organisations should consider training and education needs for health professionals in developing the skills and expertise to use patient decision aids effectively in consultations about medicines with patients, and their family members or carers where appropriate.

Organisations should consider identifying and prioritising which patient decision aids are needed for their patient population through, for example, a local medicines decision‑making group. They should agree a consistent, targeted approach in line with local pathways and review the use of these patient decision aids regularly.

Organisations and health professionals should ensure that patient decision aids prioritised for use locally are disseminated to all relevant health professionals and stakeholder groups, such as clinical networks.

Organisations should consider computerised clinical decision support systems (taking account of existing systems and resource implications) to support clinical decision‑making and prescribing, but ensure that these do not replace clinical judgement.

Organisations should ensure that robust and transparent processes are in place for developing, using, reviewing and updating computerised clinical decision support systems.

Organisations should ensure that health professionals using computerised clinical decision support systems at the point of prescribing have the necessary knowledge and skills to use the system, including an understanding of its limitations.

When using a computerised clinical decision support system to support clinical decision‑making and prescribing, ensure that it:

• identifies important safety issues

• includes a system for health professionals to acknowledge mandatory alerts. This should not be customisable for alerts relating to medicines-related 'never events'

• reflects the best available evidence and is up‑to‑date

• contains useful clinical information that is relevant to the health professional to reduce 'alert fatigue' (when a prescriber's responsiveness to a particular type of alert declines as they are repeatedly exposed to that alert over time).

Organisations should consider a multidisciplinary team approach to improve outcomes for people who have long‑term conditions and take multiple medicines (polypharmacy).

Organisations should involve a pharmacist with relevant clinical knowledge and skills when making strategic decisions about medicines use or when developing care pathways that involve medicines use.