Optimising medication

While medications are a force for good, they continue to be a source of avoidable harm when errors occur or when there is insufficient monitoring of high-risk medications (World Health Organization (WHO), 2016). While the level of adverse events related to medications in primary care is lower than those in other sectors, the data may reflect under-reporting (WHO, 2016) and do not include medication errors reported by community nurses, whose data appear within that of their employing organisation (Care Quality Commission (CQC), 2019). Further, given the large number of prescribed medications that form a part of primary care delivery, there is still the potential to cause considerable harm in absolute terms.

Avery et al (2013) found prescribing and/or monitoring errors in 4.9% (296/6048) of all prescriptions in a retrospective analysis of a 2% random sample of patient records over a 12-month period across 15 general practices in three primary care trusts. Most errors were of mild or moderate severity, with those aged 65–74 years having a 68% excess risk and those aged ≥75 years having a 94% excess risk. Thus, for patients aged ≥75 years receiving at least one medication, the prevalence was 41.9%, but for patients receiving five or more medications over the data-collection period, the prevalence of error was 32.3%, and for those receiving 10 or more medications, the prevalence was 48.8% (Avery et al, 2013). Garfield et al's (2009) systematic review concluded that only 4–21% of patients achieved the optimum benefit from their medication. The review found quality issues at every stage of the medication process, with several stages having error rates of 50% or more, the absence of repeat prescribing reviews, poor primary–secondary care interface prescribing and poor patient communication and patient adherence.

The recent CQC (2019) report arising from the organisation's inspection visits highlighted similar issues to those described by Garfield et al (2009) and Avery at al (2013). Community nurses can contribute to medication safety by helping to monitor high-risk medications and highlighting concerns regarding non-adherence to the relevant National Institute for Health and Care Excellence (NICE) treatment guidelines, as well as helping people receiving home nursing and their carers to understand their medications and any changes arising from a hospital contact, such as an outpatient appointment or admission. The Transfer of Care around Medicines (TCAM) initiative supported by the Academic Health Science Networks is designed to improve medication safety and the quality of care of patients following a hospital discharge through hospitals and local pharmacies working together. TCAM in Cheshire and Merseyside (2019) is reported to have saved the NHS £11 million, with approximately 60% of discharged patients having three or more changes made to their medications, and only 10% of older patients being discharged with the same medication that they were taking before hospital admission.

The use of medications is expected to increase given the ageing population. The district nursing service can play a crucial role in both monitoring the effect of prescribed medications and helping clients and their carers to become actively involved in their own medication management and providing aids to minimise non-adherence (WHO, 2016).