In this edition of WPR the All Wales Medicines Strategy Group explores Wales’ approach to the third WHO patient safety challenge, ‘Medication Without Harm’.
Medicines have contributed to major improvements in health globally. However, unsafe medication practices (including medication errors) are also a leading cause of harm to patients worldwide. In 2017 the World Health Organisation (WHO) launched its third WHO Global Patient Safety Challenge, ‘Medication Without Harm’, which proposes a range of solutions to remove some of the barriers preventing safe medication practices. The aim of the challenge is to reduce the level of severe, avoidable harm related to medications by 50 per cent over five years, globally. (1)
Wales’ Chief Pharmaceutical Officer, Andrew Evans, has commissioned Improvement Cymru (formerly 1000 Lives) to lead a national Medicines Safety Programme for Wales built on the recommendations in ‘Medication Without Harm’ and the 2018 report, ‘A Healthier Wales – Our Plan for Health and Social Care’. Paul Gimson, Programme Lead for Primary Care and Medicines Safety at Improvement Cymru, is leading the programme and at a workshop held on 26th November, around 50 delegates from across Wales reviewed the resources available to take the programme forward nationally, and what further developments might assist in achieving the programme’s goals.
WHO has identified four fundamental domains underpinning the Medication Safety Challenge – Patients and the Public, Medicines, Healthcare Professionals, and Systems and Practices of Medication. They have also identified three key areas for action – Polypharmacy, High-Risk Situations, and Transitions of Care and corresponding WHO technical reports highlighting these action areas and tools for improvement are now available. (2)
High-Risk Situations in Medication Safety addresses medication factors (high-risk (high-alert) medications), provider and patient factors and systems factors such as the work-environment which are associated with the greatest risk of medication-related harm. The All Wales Medicines Strategy Group (AWMSG) has published resources on the safe and effective use of certain high-risk (high-alert) medicines such as anticoagulants and opioids.
AWMSG has also produced guidance focussing on the at-risk and the frail older person and use of medicines in high-risk situations. The All Wales Policy for Medicines Administration, Recording, Review, Storage and Disposal sets out the minimum standards of practice that must be adopted by all healthcare employees involved in the administration, recording, review, storage and disposal of medicines in Welsh hospitals. Several nationally-agreed AWMSG prescribing indicators have enabled Wales to observe and then influence long-term trends in prescribing of relevant medicines.
The Medication Safety in Polypharmacy report addresses an increasing challenge, the concurrent use of multiple medications (including prescription, over-the-counter, and traditional / complementary medicines). Polypharmacy is becoming more common as people live longer with more than one (and sometimes several) concurrent medical conditions (multimorbidity). However, some aspects of polypharmacy may occasionally be inappropriate and associated with an increased incidence of adverse events. AWMSG has produced guidance to support polypharmacy management, including guidance on de-prescribing (stopping medicines) when clinically-appropriate.
The WHO report, ‘Medication Safety in Transitions of Care’ centres around the points where a patient moves to, or returns from, different settings to receive healthcare, including the home, hospital, residential care and out-patient settings. Medication errors may occur at these transitions if communication is inadequate.
Medicines reconciliation is the process of identifying the most accurate list of a patient’s current medication and comparing it with the list currently in use, recognising any discrepancies, and documenting any changes, to obtain a complete and accurate list of medications. AWMSG has developed a multidisciplinary Medicines Reconciliation Policy to guide the healthcare professional in this important process. Welsh Government, in conjunction with GPC Wales, has also implemented a national Quality Assurance and Improvement Framework for 2019-2020, of which medication-related harm is an important part.
General practices will have access to an online prescribing safety dashboard to help to drive quality improvement.
Similar progress will be expected at cluster and health board level, where aggregated safety data will be provided, supported by the AWMSG reports on the All Wales National Prescribing Indicators to inform appropriate educational interventions.
The Discharge Medicines Review
(DMR) service was introduced in Wales in 2011 as part of the community pharmacy contractual framework. It now allows community pharmacists secure access to the medicines information in the patient’s electronic Discharge Advice Letter generated in secondary care by the Welsh Clinical Portal’s Medicines Transcribing and e-Discharge system, in order to complete an online DMR after the patient is discharged into the community. Greater uptake of this resource raises exciting possibilities in relation to further improving medication safety.
NHS Wales thus already has a range of valuable tools to support the safe
use of medicines. However, it’s also important that healthcare professionals in Wales, including pharmacists, continue to be offered the opportunity to develop their quality improvement skills through Improving Quality Together training so they can choose the appropriate improvement tools as they and their colleagues seek to eliminate harm, variation and waste.
‘A Healthier Wales – Our Plan for Health and Social Care’
The plan for ‘A Healthier Wales’, published in 2018, highlights the importance of providing more services outside of hospitals, closer to home
or at-home whenever possible, and identifies safer medicines management as one-of-six clinical areas for improvement activity. (3) To achieve this, good communication between care settings is vital, ideally supported by a single digital record. An important component of efficient communication will be The Welsh Hospital Electronic Prescribing, Pharmacy and Medicines Administration project to replace paper-based drug charts in secondary care with a digital solution. (4)
The plan also emphasises the importance of making sure we keep listening to the people who use our health and social care services. In this partnership, we must apply co-productive principles as part of prudent healthcare, where healthcare professionals and citizens collaborate in an equal partnership to reach solutions which work for everyone.
1. The third WHO Global Patient Safety Challenge: Medication Without Harm. https://www.who.int/patientsafety/medication-safety/en/ ((accessed 24/11/2019)
2. World Health Organization. Medication safety in key action areas, World Health Organization 2019. https://www.who.int/patientsafety/medication-safety/technical-reports/en/ (accessed 24/11/ 2019)
3. Welsh Government. A healthier Wales: long term plan for health and social care. https://gov.wales/healthier-wales-long-term-plan-health-and-social-care (accessed 24/11/2019)
4. NHS Wales Informatics Service. https://nwis.nhs.wales/systems-and-services/secondary-care/ (accessed 24/11/2019)