{"id":586,"date":"2019-07-09T08:57:23","date_gmt":"2019-07-09T08:57:23","guid":{"rendered":"http:\/\/proriskcare.co.uk\/?p=586"},"modified":"2019-07-09T08:57:23","modified_gmt":"2019-07-09T08:57:23","slug":"medicines-in-health-and-adult-social-care-learning-from-risks-and-sharing-good-practice-for-better-outcomes","status":"publish","type":"post","link":"https:\/\/proriskcare.co.uk\/?p=586","title":{"rendered":"Medicines in health and adult social care: Learning from risks and sharing good practice for better outcomes"},"content":{"rendered":"

Introduction<\/h2>\n

This report by the CQC brings together what they have discovered through their regulatory activity about the risks from medicines. It raises important issues for everybody involved with medicines\u00a0\u00a0 in all health and adult social care settings. There has been a lot of work to ensure safer use of medicines across services, but there are still areas to be improved. The CQC is keen that all health and care providers understand the risks, and are able to apply learning from these to \u00a0enable better outcomes for people using services.<\/p>\n

Providers often state that examples of good practice are a useful tool to help them get thinking about the improvements they can make in their own services. The CQC\u2019s\u00a0 report shares some good practice and innovative ways of working. A separate, blog part 2, contains some of these examples.<\/p>\n

The six most common areas of risk with medicines across health and care.\u00a0<\/strong><\/h1>\n

1.\u00a0\u00a0 Prescribing, monitoring and reviewing<\/h2>\n

Guidance from the General Medical Council is clear that professionals are responsible for the prescriptions they sign and for their decisions and actions when supplying and administering medicines, or authorising or instructing others to do so. Prescribers and pharmacists supplying medicines have a responsibility to keep patients safe and to tell them about any risks in using a medicine. Carrying out timely medicines reviews is also key to ensuring that people\u2019s medicines remain both safe and e\ufb00ective.<\/p>\n

Monitoring patients is an essential component of the prescribing process. This covers the initial prescribing to how people\u2019s medicines are monitored over the long term to\u00a0 ensure\u00a0 that they remain safe and e\ufb00ective. The CQC found many examples of risk and unsafe practice across a range of health and social care settings.<\/p>\n

2.\u00a0\u00a0 Sta\ufb00 competence & workforce capacity<\/h2>\n

The CQC analysis showed that sta\ufb00 were not always trained and assessed as competent to carry out aspects of their roles. This applied to both health and social care settings. In some examples, there were not enough competent sta\ufb00 in both domiciliary home care and residential care home settings to administer medicines to people.<\/p>\n

The concept of ongoing monitoring and assessing competency, particularly after medicines administration errors, was not implemented in some organisations. The CQC analysis also revealed examples of services that did not have enough sta\ufb00 to carry out basic duties, such as essential monitoring after administering certain medicines, and carrying out medicines reconciliation.<\/p>\n

The analysis also highlighted other common areas that contribute to risks, which a\ufb00ect medicines optimisation as a whole across all sectors. For example, having good governance (e\ufb00ective audit, policy and procedures, and incident reporting) and keeping clear and accurate records.<\/p>\n

3.\u00a0\u00a0 Supply, storage & disposal<\/h2>\n

Problems with the supply of medicines could be linked to both prescribing and to problems with stock ordering and control. The CQC found that a wide range of medicines were not always \u00a0stored appropriately, including intravenous fluids and controlled drugs. They also found that some medicines were not stored at the manufacturer\u2019s recommended temperature, which can compromise their e\ufb00ectiveness and pose a risk to patient safety<\/p>\n

4.\u00a0\u00a0 Administration<\/h2>\n

Issues with administration were commonly linked to poor record keeping, which included incorrectly transcribed medicines administration records and failure to record administration.<\/p>\n

5. Transfer of care<\/h2>\n

Through their regulatory work in health and care services, the CQC has seen an increased risk of poorer experiences and outcomes when people\u2019s care is transferred between services.<\/p>\n

The CQC found examples where people\u2019s safety was put at risk when they had been discharged from hospital to care homes, or to their own home, without any guidance on how to take\u00a0 medicines, or in some cases without a supply of medicines at all. They also saw examples of unsafe care when information about changes to medicines was either not transferred soon enough, not accurate or not transferred at all.<\/p>\n

6.\u00a0\u00a0 Reporting and learning from incidents<\/h2>\n

Reporting incidents and near misses, and sharing the learning from them, is crucial to reduce the risk of a similar event happening again. The CQC analysis showed that medicines incidents were not always recorded, and low recording rates were sometimes associated with a culture of fear within organisations about reporting mistakes. They also found examples of providers who lacked the insight to investigate and share learning within their organisations.<\/p>\n

Antibiotics and antimicrobials<\/h2>\n

Specific issues around prescribing and administering antibiotics were uncovered in the Inspection Reports and revealed examples where antimicrobials were:<\/p>\n