In March 2017, the World Health Organisation (WHO) launched its third Global Patient Safety Challenge, Medication Without Harm, with the ambitious goal of reducing avoidable medication-related harm by 50% worldwide over the next five years.
This ambitious challenge was taken up last week by Jeremy Hunt, the Secretary of State for Health and Social Care. Speaking at the World Patient Safety, Science and Technology Summit, he highlighted that an estimated 237 million drug errors occur each year in England, and set out new proposals to tackle what he described as ‘appalling levels of harm and death that are totally avoidable’. The government’s new proposals include accelerating the rollout of electronic prescribing systems in hospitals, decriminalising errors by pharmacists to encourage learning and transparency, and expanding the use of PINCER, an IT tool recently supported by the Health Foundation that identifies patients at risk of hazardous prescribing.
So far so good. But medication safety extends far beyond the work of the NHS, into social care and other sectors, and here the new government strategy left questions hanging. Very little was announced last week to improve medication safety in social care. And, worryingly, with no solution to the social care funding crisis in sight, the working environment in care homes will remain hugely pressured. This only increases the likelihood of human factors leading to errors.
My own experience in this area comes from supporting adults with severe learning disabilities. I recognised each of the four specific challenges that the WHO campaign identifies: medicines are sometimes complex and can be puzzling in their names or packaging; patients and the public are not always ‘medication-wise’; health care professionals sometimes prescribe and administer medicines in ways and circumstances that increase the risk of harm; and systems and practice of medication are complex and often dysfunctional. Working in the often-overlooked setting of residential care for adults with learning disabilities, I observed many of these complex issues in practice.
Each person I supported lived with a unique set of symptoms that were managed with a complex medication regime. Due to their learning difficulties, our residents often struggled to understand or manage their own medication. Residents sometimes refused important medicines (depending on the drug, this could be treated as a medication error) or were unable to request the medication they needed. The doses and combinations of drugs varied over time as symptoms or prescribing behaviours changed. The fact that many drugs are incredibly similar in name and appearance only made things harder. Electronic prescribing and administration systems had not yet reached the rural residential home where I worked. The lack of digital systems added several pages to the extensive daily logbooks for each resident.
With diligence, these challenges were usually surmountable, but they were made much harder by wider staffing pressures. A day at work for me would usually begin with an introduction to the faces of new agency support workers – friendly, but with no experience in their new setting and no knowledge of the complex care needs of the residents. Any remaining staff shortages would then influence the planning of daily agendas, often resulting in cancelled outings and activities, and disappointed residents. Staff with medication training were often overstretched, expected to organise, prepare and distribute complicated medication programmes in the face of frequent distraction.
In such an environment, despite being full of good people working their hardest, it can be hard to summon up the ‘infectious enthusiasm to challenge and find new ways of designing out error’ for which the Health and Social Care Secretary has appealed. All too often, the focus was on fighting fires.
The research paper published alongside the government’s report last week highlights how care homes have the highest reported error rates per patient, ‘leading to a disproportionately high overall number of errors’. This suggests that steps to improve medication safety in this sector, such as improving the links between pharmacies and care homes and supporting e-prescribing systems for care home staff, could reap dividends in reducing harm. But despite this, the government’s recommendations last week were predominantly focused on the NHS.
A scheme to reduce over-prescription and unnecessary medication in care homes in Northumbria is a good example of what can be achieved. With a small Health Foundation grant, the team there introduced new medicine reviews that were designed to simplify residents’ medication. As a result, the amount of medicine given to residents was reduced by 17%. This not only decreases the likelihood of error but liberates staff to spend more time with the people they care for. In Northumbria, this freed up an extra hour per day for nurses to focus on caring.
Last week’s announcement contained some important steps forward and offered encouragement that we can make progress towards the Medication Without Harm goal. But if the government’s strategy is to live up to the aspirations embodied in the department’s recent name change – placing social care alongside health – then the challenges outside the NHS will need to be addressed too.
Oliver Smithson (@oliver_smithson) is the Improvement Intern at the Health Foundation.