Reducing harm from high-risk medicines

Non-steroidal anti-inflammatory drugs (NSAIDs), such as Aspirin and Ibuprofen, Diclofenac and Naproxen are associated with more emergency hospital admissions than any other class of medicine.

The most common harms associated with NSAIDs include stomach ulcers gastrointestinal ulceration and bleeding but they can also cause heart and kidney complications.

To help reduce this potential harm, Healthcare Improvement Scotland's ihub introduced measures to support pharmacy teams to give key safety information to every patient in Scotland, every time an NSAID is sold or dispensed in a pharmacy.

The need for clearer information
Research tells us that patients are not always adequately informed about how to take these over-the-counter medicines when they collect them from pharmacies.

To reduce the potential harm of taking NSAIDs, we were awarded a grant from The Health Foundation to improve patient safety by strengthening the contribution of community pharmacy and improving communications within primary care teams. We aimed to achieve this through the formation of a collaborative and the use of established improvement tools and approaches focused on three areas of interest: High Risk Medicines (NSAIDs), Safety Culture and Medicines Reconciliation.

This funding allowed work to be piloted by teams in four NHS boards:

As a result the NSAIDs Communication Care Bundle was created. As part of their pilot work, NHS Highland then developed a toolkit to further support pharmacy teams to implement the Communication Care bundle. The toolkit was adopted and refined by the ihub and distributed to every community pharmacy in Scotland in 2018.

Toolkit for community pharmacies
The toolkit provided each community pharmacy with:

  • a Communication Care Bundle Guide which gave the reasons for this work and to support them to implement the bundle in their pharmacy.
  • prompts to help remind the pharmacy teams to have the NSAID conversation with their patients including a till prompt placed at the points of sale or dispensing. NSAID stickers can also be put on prescription bags containing NSAIDs.
  • NSAIDs and Medicines Sick Day Rules cards which help give pharmacy team members confidence when giving the messages to patients and act as a handy reminder to patients when they get home.
  • Quality Improvement (QI) tools including a data collection sheet and run charts to help pharmacy teams improve how consistently they deliver the messages to their patients and customers.

The toolkit helps pharmacy teams communicate three key messages to help their patients take NSAIDs safely:

  1. Always take this medicine with or after food.
  2. Tell us if you get any side effects (explain what these might be).
  3. Be aware of the medicine sick day rules (explain the rules).

We supported pharmacies with this work by collaborating with NHS Education for Scotland (NES) to facilitate roadshows and produce a webinar to help them learn more about how they can make NSAIDs safer for their patients.

Tailored support for dispensing GP practices
In remote and rural areas in Scotland where patients don't have access to a community pharmacy, dispensing GP practices issue medications. In March 2019 we provided a bespoke NSAIDs toolkit to these practices to implement the NSAIDs Communication Care Bundle. A webinar specifically for this group was held in 2019 to support these teams further.

Benefits for both patients and staff
Patients and staff in pharmacies across Scotland have benefited from the toolkit: patients who take NSAIDs are now being given a greater understanding of their medication; they are being made aware of potential serious side effects and what to do if they are sick.

One patient commented after having the conversation in their local pharmacy:
"Now that I know, I'll take my NSAID with food."

The toolkit engages with all staff involved in the dispensing of medicines, from the pharmacist to the part time retail store assistants, and gives them the confidence, knowledge and prompts they need to have the NSAIDs safety conversation with patients.

Clare Morrison from NHS Highland explained that:
"Everything that became part of the pack such as the stickers and cards came from staff who were doing the initial piloting – that's why it really worked."

Implementing the toolkit has empowered pharmacies to adopt QI activities in a way that works for them locally. One pharmacy told us that when they had run out of NSAIDs stickers they tried using a pink marker pen instead and found this this worked so well for them they have continued with this approach.

The QI tools give staff an easy way to capture and record their data. This helps them to identify where they need to focus their improvement work and makes it simple to share progress. Gathering and displaying the data has increased engagement across the pharmacies by giving them ownership of their improvement journey.

The next step is to complete further evaluation of this work.

More information and helpful resources
See the NSAIDs toolkit at

The communication bundle supports pharmacy teams to deliver key messages to patients being dispensed NSAIDs. We are continuing to develop this work through the new and recently launched NSAIDs Safer Care bundle. This acts as a prompt to pharmacists to consider key points, including a patient needs assessment and identification of 'high risk' patients along with potential interventions when processing a prescription for NSAIDs.

There is more information about our work on the Primary Care and SPSP Medicines web pages