Medicines in health and adult social care: learning from risks and good practice for better outcomes

care quality commission

The independent regulator of health and social care in England

Medicines in health and adult social care

Learning from risks and good practice for better outcomes

Medicines in health and adult social care

Today, 6 June 2019, we have published a report sharing the learning from risks and good practice in medicines optimisation, which we have found on our inspections. 

Many of the services that CQC regulates have a role in managing medicines. Through inspection, we have seen that medicines can present a clear risk to people when not used properly.

When CQC inspects health and care services we assess how well they meed people's needs. As part of this, we look at how people's medicines are optimised. Medicines optimisation is the safe and effective use of medicines to enable the best possible outcomes for people. It also looks at the value that medicines deliver, making sure that they are both clinically and cost effective, and that people get the right choice of medicines, at the right time, with clinicians engaging them in the process.

We do this through a dedicated team of pharmacy professionals who work across the country providing specialist advice on the use of medicines in all settings. This includes being on site at inspections, inputting into decisions on enforcement and supporting CQC's policy teams. 

From our analysis, we have categorised the most common areas of risk with medicines across regulated health and adult social care services. You can read these in more detail, along with our suggested actions for all health and social care providers, in the main report. 


The report also examines what a number of these themes mean in the context of primary care. In the analysis of risks in primary care services, the widest range of issues relating to medicines were found in GP practices, most likely because of their diverse scope of practice.

Every year, NHS GPs carry out over 300 million consultations and prescribe over a billion prescription items. Issues in dental practices, urgent care centres and out-of-hours GP services were slightly less wide-ranging, and mostly focused around administration, recording and storage issues.

We explore some of these themes in more detail below, along with examples of good practice, but you can jump straight to the primary care section of the report by clicking from the contents section of the main report.


Prescribing, monitoring and reviewing high-risk medicines

A key theme identified in inspection reports was appropriately monitoring and reviewing patients’ prescriptions of medicines, specifically high-risk medicines.

Infrequent medicine reviews led to problems with repeat prescriptions, as providers continued to authorise prescriptions of high-risk medicines, putting people at risk of harm. The General Medical Council provide guidance in this area and we expect this to extend to appropriate monitoring and review to ensure that it is safe to issue a repeat prescription. 

Practices with effective systems that monitor high-risk medicines well often have good administrative support, together with timely input from clinicians. For example, they carry out regular searches on electronic prescribing systems to proactively identify patients who are prescribed high-risk medicines, and when they need a review, including any that may be overdue and when their blood (or other) tests are due. Software packages can help to mitigate risk and improve safety by highlighting relevant factors.

We saw a number of good examples and share them in the report. 


Managing emergency medicines

Where we found poor quality medicines management, this was often linked back to a lack of procedures or systems, and an ineffective system of checks. This meant that we found emergency medicines on inspection that were:

  • not available
  • out of date
  • stored inappropriately.

We expect to see that providers in primary care have made a comprehensive assessment of what constitutes an appropriate stock of emergency medicines for a location.

We have published mythbusters in general practice and in dentistry to help providers in this area. 



Staff skill mix and competence

It is important that all primary care providers have the right the skill mix required for good medicines optimisation. 

We found that pharmacists in some GP practices were deployed to undertake medicines reviews for patients who had recently been discharged from another healthcare provider. 

Some practices give the patient a print-out of their monitoring results along with an explanation of the results, information about their medicines and why they need to take them, as well as lifestyle advice. 

Others add specific information about people’s medicines to the prescription form, so that this is included on the pharmacy dispensing label. This can be helpful to some patients who take multiple medicines.

Providers also need to ensure that all staff who administer, prescribe, review and dispense medicines are appropriately trained to do so. Our analysis found that this was not always the case.


Actions for primary care providers

Based on the risks identified with medicines use in primary care settings, we encourage providers to take the following action to ensure that medicines are managed safely:

  1. A programme of monitoring helps to ensure safe, high-quality prescribing by all prescribers. This should include reviewing practice processes to monitor medicines, particularly high-risk medicines, regularly auditing adherence to national guidance such as NICE guidelines, and updating prescribing following national patient safety alerts. Using prescribing software effectively can facilitate these activities.
  2. Internal systems and processes need to enable accurate and timely changes to prescriptions for example, when patients are discharged from hospital and after regular medicines reviews for patients with long-term conditions.
  3. It is important to make a comprehensive assessment of what constitutes an appropriate stock of emergency medicines for your location. Stocks of medicines on site and those for home visits need to be checked regularly to ensure they are in date and readily accessible in an emergency.
  4. There is great benefit in GP practices working more closely with pharmacy professionals to focus on medicines optimisation, as using their expertise can reduce pressure on their practice. All primary care providers can benefit from the skill mix of community pharmacists, practice pharmacists and pharmacy technicians.
  5. In order to learn from medicines incidents in general practice, these need to be reported consistently and statutory notifications made when appropriate. Having a good process to review and discuss significant events helps to understand and share learning.

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