NICE has joined forces with the National Patient Safety Agency to issue the first-ever patient safety guidance to the National Health Service.

Specifically, the guidance is designed to help trusts improve their processes so that all medicines being taken by a patient before they are admitted to hospital are properly recorded when they walk through the doors.

According to the NPSA, there have been 7,070 incidents of medication errors involving admission and discharge, leading to two fatalities and 30 that caused severe harm, highlighting the urgent need to reduce the number of prescription errors in hospitals that take place because of a lack of knowledge of patients’ prior treatment regimens.

“It can therefore be very difficult to get an accurate picture of a patient’s medication upon hospital admission,” noted Dr John Pounsford, Patient Safety Advisory Committee member. “It is very important for pharmacists and their teams to cross check what the patient tells them with their GP and their carer to get an accurate record,” he added.

To improve medicines reconciliation, the agencies recommend that:

- Healthcare organisations admitting adult inpatients should ensure they have procedures in place for medicines reconciliation for both elective and emergency admissions; and
- As well as standard systems for collecting and recording data on medications, policies for medicines reconciliation on admission should also ensure that: pharmacists are involved as soon as possible; the responsibilities of pharmacists and other staff in the process are clearly defined; and that strategies are incorporated to obtain from patients with communication difficulties.

“Implementation of this guidance will help to ensure there is a system in place in all hospitals to minimise the risk of drug errors,” said NICE chief executive Andrew Dillon. “As part of this, we are also recommending that pharmacists and their teams are involved as soon as possible to aid in cross checking medications with patients, their GP and carers, when necessary, to get a clear picture of the medicines patients are taking”.

NICE and the NPSA issued draft guidance on streamlining the processes for medicines reconciliation as well as recommendations for the prevention of pneumonia in mechanically-ventilated patients back in September.

“Ventilator-associated pneumonia and ineffective medicines reconciliation at hospital admission are significant causes of patient morbidity and mortality and therefore present important safety concerns that need to be addressed,” said Dillon at the time.

Progress in safety
Meanwhile, the NPSA has today unveiled its report Safety First: One Year On, which it says, shows significant progress has been made in putting patient safety at the top of the NHS’ agenda.

Achievements during the year include: the establishment of a National Patient Safety Forum, which meets regularly to set agendas and check progress; the creation of Patient Safety Action Teams through a partnership with strategic health authorities; and a Patient Safety Charter agreed and signed by over 20 organisations.

However, despite the advances, the NPSA warns that there is still much to be done to ensure that all NHS organisations have patient safety at the top of their priorities, a point by stressed Chief Medical Officer, Sir Liam Donaldson: “We must not believe that the job is complete. This is only the beginning of the journey to make healthcare safer. But significant progress has been made.”