Getting medicines right


A case study describing action by North Devon Healthcare NHS Trust to improve the medicines management pathway for patients receiving acute unplanned episodes of care

What was the aim?

Optimising and preventing harm from medication on admission and discharge in an acute trust can be complex. The trust wanted to improve the medicines management pathway for patients receiving acute, unplanned episodes of care.

What was the solution?

Northern Devon Healthcare NHS Trust’s pharmacy and medical assessment unit (MAU) teams identified opportunities to improve the medicines management pathway. As a result, South Western Ambulance Service NHS Foundation Trust’s paramedic crews agreed to prompt patients being taken to Northern Devon District Hospital to bring their medicines with them. This triggered other initiatives within Northern Devon Healthcare to improve medicines management. 

  • The enhanced recovery team was briefed on the importance of ‘getting medicines right’, and new questions on medication were added to the trust’s discharge planning information booklet to make referral to a pharmacist easier following admission. 
  • Occupational therapists agreed to ask patients about their medicines when preparing for discharge.
  • The MAU team educated each new intake of junior doctors in the importance of ‘getting medicines right’ on admission.
  • The hospital pharmacy team made sure it was ready to answer patients’ questions about their medicines.
  • The trust runs an annual public awareness campaign, ‘Talk About Your Medicines’, to encourage patients to ask questions about their medicines and be referred to the pharmacy team for advice if needed.
  • The trust worked with the local pharmaceutical committee to signpost patients to community pharmacy medicines support services following discharge.

What were the results?

  • The number of patients bringing their medicines into hospital rose from 7% in July 2017 to 67% in February 2018.
  • Staff use patients’ own medicines as an information source when completing medicines reconciliation on admission. This encourages patients to talk about their medicines and whether they are experiencing any problems.  
  • The number of unintended omissions of medication reduced from 11 high risk and 32 other medicines in 2015/16 to two high risk and 20 other medicines in 2017/18.
  • The number of patients able to administer their own medication has increased, which saves nursing time and reduces the risk of unintended omissions of medication on busy wards.      
  • Using patients’ own medicines has reduced medicines waste and time taken dispensing medication that patients already have and do not need.  

What were the learning points?

  • Despite procedures for ‘getting medicines right’, teamwork and effective communication are essential.
  • Measurement and feedback to staff are important for checking that you are ‘getting medicines right’ for your patients.

Next steps

The trust plans to develop a patient experience questionnaire on medicines. 

Want to know more?

Joy Davey, Medicines Safety and Governance Pharmacist,

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