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NHS must do more to prevent harm to patients from prescribed medicines after leaving hospital, says CQC

27 October 2009

The NHS may be at risk of failing to prevent harm to patients from medicines unless it improves sharing of vital information when people move between services, says the Care Quality Commission (CQC).

The regulator has publishes findings from its study of how well patients’ medication is managed after leaving hospital. It visited 12 primary care trusts (PCTs), as commissioners of GP and hospital care, and surveyed 280 of their GP practices.

There are risks to the safety of patients when they are prescribed medicines, particularly after leaving hospital. Incidents involving medication, such as prescribing errors and failures to review medication after discharge, were the fourth most commonly reported to the National Patient Safety Agency during 2008. One study estimates around 4% of all hospital admissions are due to preventable medicine-related issues.

During its visits, the CQC saw some evidence of good practice, but also found the following concerns: GP practices and hospitals do not always share timely, complete patient information on medication changes when people move between services; reviewing and updating of GP records is sometimes left to administrative staff; GPs do not routinely review new medication with a patient after they leave hospital; and monitoring and learning from serious incidents is patchy.

From April 2010, all trusts will be required by law to register with CQC and must meet a new set of standards. Effective management of medicines will be a requirement of registration, and CQC will take action where trusts fall short of meeting this. The regulator therefore urges all trusts and GP practices to use the findings of its study to identify problem areas in preparation for registration.

CQC, which is championing joined-up services across the health and adult social care system, found overall that GP practices have good repeat prescribing systems in place to reduce risks associated with patients taking medication for longer than necessary, particularly if their medication changed while in hospital.

It also found patients taking high-risk medicines, such as treatment for blood clots, generally have their medication reviewed by a GP soon after discharge from hospital to spot potential problems and discuss any side-effects of newly prescribed drugs.

But 81% of GP practices surveyed said when hospitals sent them summaries of the care they had provided to patients, details of medicines prescribed were incomplete or inaccurate ‘all of the time’ or ‘most of the time’. This is particularly concerning as a GP may subsequently prescribe incompatible drugs, which may lead to harm.

The CQC also found some practices were not systematically providing hospitals with information on: previous drug reactions (24%); other existing illnesses, known as co-morbidities (14%); or known allergies (11%), when patients are admitted. This means hospitals could prescribe medicines that are harmful.

Cynthia Bower, CQC’s Chief Executive, said: “We know that incidents related to medication can cause people significant problems and sometimes unnecessary harm and distress.

“Not all adverse drug reactions are preventable, but the potential risks are clear. It is important that basic systems to share essential patient details are working effectively to get the right information to clinicians at the right time to minimise these risks. It is clear from this study that services have some way to go before this routinely happens in the way it should.

“People have a right to expect clinicians to know details about each stage of their care, and in this day and age they are right to do so. It’s not possible for a clinician to make good decisions about care unless they have key information about a patient.

“There needs to be a change of attitude in the NHS in recognising how important it is for clinicians to pass the baton smoothly between services in order to offer person-centred, integrated care.”

The CQC’s study highlights several areas needing improvement. It found that:

Information shared between GPs and hospitals when a patient moves between services is often patchy, incomplete and not shared quickly enough.

If a hospital does not have complete information from the GP on a patient’s current medication, and they are subsequently prescribed an incompatible or duplicate drug, it can lead to an adverse reaction. And if a patient’s medication changes while in hospital, clear updated information should then be sent to the GP upon discharge (a discharge summary).

Looking at how well GPs share patient information to hospitals, CQC found that:

  • In non-emergency cases 98% of GP practices said they provide the hospital with a list of all medicines currently prescribed for patients. But some practices are not systematically providing information on: previous drug reactions (24%); co-morbidities (14%); or known allergies (11%).
  • Nearly all the PCTs (11 out of 12) did not have reliable systematic knowledge of whether GPs send correct information to hospitals at the right time.

When CQC asked the GP practices about the quality of information within discharge summaries from hospitals, it found that: 

  • Eighty-one per cent report that details of medicines prescribed by hospitals was incomplete or inaccurate ‘all of the time’ or ‘most of the time’.
  • Eighty-eight per cent report that the summary of diagnosis on admission to hospital was incomplete or inaccurate ‘all of the time’ or ‘most of the time’.
  • Almost half (47%) said summaries were received in time to be useful for a patient’s first follow-up GP appointment either ‘some of the time’ or ‘hardly ever’. Fifty-three per cent said ‘all of the time’ or ‘most of the time’.
  • When asked how often summaries were inaccurate or incomplete, 72% said ‘some of the time’ or ‘most of the time’, and 27% said ‘hardly ever’ or ‘never’.
  • Only four of the PCTs audited the quality and timeliness of discharge summaries and were able to use the results to provide a view of current performance.
  • In half of the PCTs (6 of 12), information on a patient’s medication is only copied to the community pharmacist if the patient was prescribed a high risk drug or using an aid to help them remember to take their medicine correctly. This is despite studies that show providing this information can prevent adverse drug events.

The CQC says GPs and PCTs must agree the level of detail to be included in the information provided to hospitals, including details on drug reactions, co-morbidities and allergies. PCTs must systematically monitor and hold GP practices to account more effectively on this, as it is critical to safety.

Acute trusts also need to greatly improve the quality of the information they provide in discharge summaries, in particular that on medicine changes. CQC advocates the roll-out of an IT system suitable for sharing this information more effectively.

Updating of GP patient records is not always carried out by clinical staff.

When discharge summaries are received by GPs, they must review and update patient records with new or amended information. If not completed properly it could result in patients being prescribed duplicate or incompatible medicines, increasing the risk of complications. The CQC found that:

  • In 17% of GP practices surveyed, patient notes are updated by managerial or clerical staff, rather than someone with a clinical background. Although clinicians checked cases, there was not enough evidence to assess the extent or quality of this oversight.
  • In two thirds of the PCTs visited (8 of 12), there were no systems for monitoring whether discharge summaries were reviewed and patient notes updated effectively within GP practices.
  • Half of the PCTs (6 of 12) did not provide GPs with specific guidance on reviewing and updating notes, and within these PCTs only 25% of GP practices had set out their own.

The CQC recommends PCTs should agree expectations for reviewing and updating patient notes, and GP practices must ensure that proper cross-checking by clinicians takes place when notes are updated by non-clinical staff.

Too few patients are offered discussions with their GP about managing their medication.

A health care professional should review a patient’s medication after they leave hospital to check it is effective, discuss side effects and spot potential problems. Patients’ involvement in this is crucial to them taking medication correctly. Of those GP practices surveyed:

  • Seventy-five percent reviewed medication within six months of discharge for patients over 65 and on one of three high risk drugs.
  • But only 55% said patients are present during medication reviews ‘most of the time’, 36% ‘some of the time’ and 5% ‘hardly ever’.

The CQC recommends GPs should, where possible, increase the number of patients who are present for their medication reviews, so people’s experience of taking the medicines can be discussed and potential problems spotted.

GPs are not consistently reporting medication incidents and errors, and PCTs are not always monitoring them.

The level of reporting of incidents from GP practices is low and variable across the PCTs visited. CQC found that:

  • Although all PCTs had developed initiatives to encourage GPs to report incidents and share learning, four PCTs could not provide evidence to suggest figures for medication errors were systematically collated, analysed and benchmarked against neighbouring trusts.
  • Only one PCT could demonstrate it had taken action to improve medicines management as a result of learning from its own incidents.
  • The NPSA recommends a medicines management report should be produced and presented to the trust board annually. However, only five of the PCTs had produced a report of this kind, and of these five, only two contained incidents reported over the previous year.

The CQC says the safety of medicines management cannot be improved if incidents and errors are not reported, and lessons learned from them. It recommends GPs should do more to capture, record and report instances to PCTs and the NPSA. PCTs should also better monitor GP practice performance in this area.

The CQC has shared its recommendations with the PCTs involved in the study, to implement the necessary improvements. It also encourages the wider NHS to learn from these findings and check that their own systems to manage medicines are sufficient to protect patients from potential harm.

The regulator will be looking at clinical governance in PCTs as progress is made towards the registration of primary care. In addition, CQC will consider how it will continue to lever improvement when the reviews it undertakes uncover poor practice.


For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

Notes to editors

Incidents involving medication were the fourth most commonly reported to the National Patient Safety Agency during 2008 (NPSA quarterly data summary, May 2009).

One study estimates around 4% of all hospital admissions are due to preventable medicine-related issues. The same study estimates that adverse drug reactions (both preventable and non-preventable) are likely to account for over 10,000 deaths in England a year, taking account of those reactions that also occur during a hospital stay. The estimated annual cost of preventable medicines-related admissions in England is £466 million. (Pirmohamed et al, Adverse drug reactions as cause of admission to hospital, BMJ, 2004.)

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