Project launched to improve patient safety regarding medication information

Research shows that the most preventable adverse drug events in primary care are due to errors in prescribing and medication monitoring; the Mental Health Medication Helper (MHMH) aims to improve service user safety in this area.

Maintaining and communicating accurate medication information across health services is an important issue for the NHS. Few safety improvement approaches have been tested in primary care, and effective implementation models that reach beyond the in-patient setting are needed. Understanding what preventable errors occur in primary care and the context in which improvement is achieved is critical to improving service user safety.

When service users are transferred across care settings there’s a risk that information about their medicines will not be transferred accurately. Service users transfer across numerous care interfaces throughout the delivery of care, and these interfaces are increased when the service user’s care is managed by multiple health care professionals.

Baseline findings from our improving the physical health of people with severe mental illness project have shown that there are issues with service users adhering to their medication, and that improvements could be made regarding communication and information provided between services.

In February 2011, the Government published the No Health without Mental Health strategy. One of the key areas of focus is integrating physical health into decisions about prescribing and monitoring. Mental health service users are often prescribed multiple medications and this is specifically the case for those with more severe mental health disorders such as bipolar disorder and schizophrenia.

A complete picture of a service user’s medication is essential for safe prescribing; not having this information readily available may result in inappropriate choices of medication. There is a wealth of research examining service user harm in hospital; however, less is known about errors in primary care. Existing studies suggest that 1–2% of primary care consultations may include adverse events, with the most common errors relating to medication and communication. There is an urgent need to reduce the risk of the occurrence of these errors.

About the project

The primary aim of the project is to develop and test the MHMH with a sample of service users. Specifically, the project will look at determining how, if at all, the MHMH promotes medication management for service users with mental health conditions in primary care and to examine how it is completed in practice. The testing period will also help to investigate health care professionals’ experiences of completing the MHMH and to use the findings of the testing to modify and improve the MHMH.

The MHMH has been designed to improve communication and recording of service users’ physical and mental health medication. Taking the form of a simple document, it will be completed by health care professionals caring for service users and will then remain in the service users’ home.

Service users will be able to use the document to help them to take the correct medication at the correct time. The document will include a diary which service users can use to log any important information about their medication. This could include any comments, concerns, suggestions, questions and side effects that they might be experiencing. These can then be discussed with their care co-ordinator, GP or Practice Nurse.

The Model for Improvement and Plan Do Study Act (PDSA) cycles will be used to test the MHMH. For more information, please contact Carianne Hunt, Research Fellow – CLAHRC for Greater Manchester, on 0161 206 1588 or via