Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

Systems for identifying, reporting and learning from medicines‑related patient safety incidents

  • Organisations should consider using multiple methods to identify medicines‑related patient safety incidents – for example, health record review, patient surveys and direct observation of medicines administration. They should agree the approach locally and review arrangements regularly to reflect local and national learning.

Medicines‑related communication systems when patients move from one care setting to another

  • Health and social care practitioners should share relevant information about the person and their medicines when a person transfers from one care setting to another. This should include, but is not limited to, all of the following:

    • contact details of the person and their GP

    • details of other relevant contacts identified by the person, and their family members or carers where appropriate – for example, their nominated community pharmacy

    • known drug allergies and reactions to medicines or their ingredients, and the type of reaction experienced (see the NICE guideline on drug allergy)

    • details of the medicines the person is currently taking (including prescribed, over‑the‑counter and complementary medicines) – name, strength, form, dose, timing, frequency and duration, how the medicines are taken and what they are being taken for

    • changes to medicines, including medicines started or stopped, or dosage changes, and reason for the change

    • date and time of the last dose, such as for weekly or monthly medicines, including injections

    • what information has been given to the person, and their family members or carers where appropriate

    • any other information needed – for example, when the medicines should be reviewed, ongoing monitoring needs and any support the person needs to carry on taking the medicines. Additional information may be needed for specific groups of people, such as children.

  • Consider sending a person's medicines discharge information to their nominated community pharmacy, when possible and in agreement with the person.

Medicines reconciliation

  • Organisations should ensure that medicines reconciliation is carried out by a trained and competent health professional – ideally a pharmacist, pharmacy technician, nurse or doctor – with the necessary knowledge, skills and expertise including:

    • effective communication skills

    • technical knowledge of processes for managing medicines

    • therapeutic knowledge of medicines use.

  • National Institute for Health and Care Excellence (NICE)