Pharmacy & Medicines Management 2018

Objectives Prescribing & Zero tolerance National Alerts Medicines Reconciliation Policies Pharmacy Services

Prescribing Medicines “The General Medical Council (GMC) states that all doctors must keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment “

BVH - A Zero Tolerance approach to Safe Prescribing “ Administering or dispensing against unclear and incomplete prescriptions within the NHS in the past has led to serious patient injury and doing so may result in charges of negligence and disciplinary action against the health professionals involved in all stages of the medication process.” Prescriptions must be clear, accurate, safe & appropriate

Zero Tolerance Procedure Be printed in clear and legible handwriting Include the full drug name Prescribers must specify the dose units clearly: Microgram: microgram (not mcg or μg), Units: UNITS (not u or iu)

Refusal to supply Exception report Blue forms-Refusal to Supply against an Unacceptable Prescription Pink forms -Situations Where a Supply against an Unacceptable Prescription Is Made By Pharmacy, This will always be on the decision of a registered pharmacist,

What medication would you give this patient?

Abbreviations should be avoided to reduce the risk of errors at all stages of the medication administration process Isosorbide mononitrate

NRLS (National Reporting & Learning System) (Previously NPSA) Review and analyse patient safety incident reports Identify common risks Implement safer practice Insulin Anticoagulants Methotrexate Lithium Potassium NRLS is a central database of patient safety incident reports. Since the NRLS was set up in 2003, over four million incident reports have been submitted. NPSA- We lead and contribute to improved, safe patient care by informing, supporting and influencing organisations and people working in the health sector.   We are an Arm’s Length Body of the Department of Health and through our divisions cover the UK health service. On Friday 1 June 2012 the key functions and expertise for patient safety developed by the National Patient Safety Agency (NPSA) transfer to the NHS Commissioning Board Special Health Authority (the Board Authority). This ensures that patient safety is at the heart of the NHS and builds on the learning and expertise developed by the NPSA, driving patient safety improvement. The Board Authority will harness the power of the National Reporting and Learning System (NRLS), the world’s most comprehensive database of patient safety information, to identify and tackle important patient safety issues at their root cause. Patient Safety Aims to reduce risks to patients receiving NHS care and improve safety. . Patient Safety The Patient Safety Division aims to identify and reduce risks to patients receiving NHS care and leads on national initiatives to improve patient safety. Through the National Reporting and Learning System (NRLS), the Patient Safety Division collects confidential reports of patient safety incidents from healthcare staff across England and Wales. Clinicians and safety experts help analyse these reports to identify common risks and opportunities to improve patient safety. Feedback and guidance are provided to healthcare organisations to improve patient safety. These include alerts to address specific safety risks, tools to build a strong safety culture and national initiatives in specific areas such as hand hygiene, design, nutrition and cleaning.The Patient Safety Division works closely with royal colleges, frontline staff and organisations, patient groups, strategic health authorities, other NHS bodies, academic centres and sectors beyond healthcare to promote patient safety. Healthcare organisations should continue to report patient safety incidents to the NRLS. Working across sectors the NHS Commissioning Board Authority will utilise patient safety incident data to analyse risk, drive learning and improve patient safety.

NPSA-Insulin (2010) 16,600 patient safety incidents Including death 26 per cent were due to the wrong insulin dose, strength or frequency one death after clinicians misinterpreted the abbreviation of the term ‘unit’. The Rapid Response Report asks NHS organisations to ensure that: • All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device (never using intravenous syringes); • The term ‘units’ is used in all contexts. Abbreviations, such as ‘U’ or ‘IU’, are never used; • A training programme is in place for all healthcare staff that are expected to prescribe, prepare and administer insulin; • All clinical areas and community staff treating patients with insulin have adequate supplies of insulin syringes and subcutaneous needles.

Anticoagulants Medicine most frequently identified as causing preventable harm and admission to hospital Ensure that patients prescribed anticoagulants receive appropriate information This Patient Safety Alert advises healthcare organisations to take steps to manage the risks associated with the prescribing, dispensing and administering of anticoagulants. Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harm and admission to hospital. On discharge- it is the doctors responsibility to book ant-coag appointments and complete their yellow annticoag book

Warfarin-Patient information Patients should be informed of: Tablet strengths/colours INR (blood monitoring)/blood tests Yellow book Side effects Food/drink interactions Drug interactions Hobbies Other healthcare professionals

DOAC’S Apixaban Rivaroxaban Edoxaban Dabigatran Still require counselling as they are high risk medicines All new DOAC’s need a ADAS referral

Methotrexate Reports of incorrect dosing frequency of oral methotrexate Oral methotrexate is a safe and effective medication if taken at the right dose and with appropriate monitoring. However, very occasionally problems with taking the medication can cause serious harm and even death. All NHS organisations should take steps to: agree local action required; provide patient information before and during treatment; update prescribing and dispensing software programmes; and review purchasing.

Opioids 12-hourly modified release preparations must be prescribed OM and ON- not eve Different routes of administration are not equivalent Breakthrough doses must be 1/6th to 1/10th of the regular opioid dose

Medicines Reconciliation “A process of identifying an accurate list of a person's current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes, thereby resulting in a complete list of medicines, accurately communicated” (NICE 2015) The aim of medicines reconciliation on admission is to ensure that medicines prescribed on admission correspond to those that the patient was taking before admission. Details to be recorded include the name of the medicine(s), dosage, frequency, and route of administration. Establishing these details may involve discussion with the patient and/or carers and the use of records from primary care. This does not include medicines review. All healthcare organisations that admit adult inpatients should put policies in place for medicines reconciliation on admission. In addition to specifying standardised systems for collecting and documenting information about current medications, policies for medicines reconciliation on admission should ensure that: pharmacists are involved in medicines reconciliation as soon as possible after admission; the responsibilities of pharmacists and other staff in the medicines reconciliation process are clearly defined; these responsibilities may differ between clinical areas; and strategies are incorporated to obtain information about medications for people with communication difficulties.

Where can you obtain drug histories from? The patient Family / carers Nursing homes MAR sheets (medication administration records) Repeat prescriptions GP surgeries Pharmacies Letters/faxes from GPs Previous admission records Previous discharge letters Patients own drugs Dosette boxes IDEALLY USE AT LEAST TWO RESOURCES This page is found in the admission booklet GREEN pen

Discharge reconciliation Ensure all NEW medicines are documented with reasons for their initiation explained. Ensure all DISCONTINUED medicines are documented – preferably with reasons. Ensure all DOSE CHANGES are documented – preferably with reasons

Policies Medicines Policy Zero Tolerance Antimicrobial formularies (adult & paeds) Gentamicin/Vancomycin monitoring Potassium VTE-dalteparin Warfarin Lithium ……AND LOTS MORE! How to access policies

Useful Resources EMC BNF cBNF Uptodate Toxbase Injectable medicines Document Library

Pharmacist Interventions

Pharmacy Services Open 7 Days 8.45-5pm Pharmacist ward visit Mon-Fri Pharmacy led-discharge service Weekend: new admissions & discharges Ward pharmacists (bleeps) One stop/meds rec. technicians Medicines Information (53791) Emergency on-call service for out of hours

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