S East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast Medicines Use and Safety P S Improving safe and accurate transfer of medicines-related written discharge information A pharmacy-led audit and service evaluation Facilitated by Linda Dodds Medicines Use and Safety Division, SPS ©East & South East England Specialist Pharmacy Services

Audit standards* 100% of discharge summaries should include: Medicines Use and Safety P S Audit standards* 100% of discharge summaries should include: ｷ Details of the consultant caring for the patient ｷ Known allergies ｷ Appropriate follow-up actions for the GP ｷ Accurate information on changes to medications (with reasons) during the admission 100% of prescription items should: ｷ Be legible and unambiguous ｷ Choice of medicine clear and correct ｷ Dose, formulation, frequency and route clear and correct *Taken from RPS guidance

Service evaluation Review of pharmacy contributions Medicines Use and Safety P S Service evaluation Review of pharmacy contributions Classification using 13 codes Assessment of clinical impact of contributions 4 Levels (NPSA definitions) Level 1: None/insignificant Level 2: Low/minor Level 3: Moderate Level 4: Severe/major

S Medicines Use and Safety P S Methodology Steering group to refine methodology & pilot the data collection forms One day collection of data (minimum) Choice of units/wards covered Data collection inputted to electronic spreadsheet & returned to MUS Local feedback of results Feedback of summated data

Data analysis Variables Medicines Use and Safety P S Data analysis Variables Care area: medical, surgical, paediatric, CHS, MH Type of admission: elective, nonelective, other Type of discharge prescription: handwritten, electronic from handwritten, electronic from electronic

Overall data 45 organisations participated 2071 prescriptions screened Medicines Use and Safety P S Overall data 45 organisations participated 2071 prescriptions screened 1904 Acute; 89 CHS; 78 MH 673 ( 32%) prescriptions required no changes by pharmacy 2880 contributions Average 1.4 contributions/prescription overall Average 2.0 for prescriptions needing change

Prescriptions by care area Steering group: keep it simple! Majority of data from medical wards Small numbers for CHS and MH

Prescriptions by type 83% of discharge prescriptions overall were electronic 65% (green) from handwritten chart 18% (red) fully electronic system 70% of discharges from urgent admissions 28% (543) elective admissions

Admission type by care area

Allergy status: Standard met in 83% scripts overall Only standard where type of prescription made a clear difference (graph bottom right)

Consultant details by care area: Standard met in 94% scripts overall

Changes since admission fully recorded by prescriber: by care area NB. Before pharmacy contribution 58% prescriptions met standard fully 27% fully recorded; 31% ‘not required’ 18% partly recorded (some information in 76%) Care area differences: 19- 49% answered NO

GP actions fully documented by prescriber: by care area NB. Before pharmacy contribution Standard met for 69% of prescriptions 40% = yes all items; 29%= ‘not required’ 31% = partly or not entered Less differences by care area

But pharmacists were able to correct some of these omissions…. 377 (13%) of contributions related to adding information on changed medicines 177 (6%) of contributions related to adding information on GP actions Unclear whether additions were from ‘Partly’ to ‘fully’ or adding information when none before

Standards relating to prescription details Prescription is legible and unambiguous A prescription that required no pharmacy contributions: 32% met standard (ie prescriptions accurate as written; Overall 673 contributions to correct issues) Choice of medication is clear and correct In terms of contributions recorded: Omitted drug/wrong drug/ inappropriate addition/drug interaction codes At least 54% met standard (Overall 946 contributions to correct)

Standards relating to prescription details Dose/formulation/frequency/route clear In terms of contributions recorded: Wrong or missing dose/ wrong or missing formulation or route/ wrong frequency/timing/duration code: Overall 871 contributions At least 58% met standard (871 contributions affected up to 42% of discharge prescriptions before pharmacy corrected)

Contributions analysis 2880 contributions overall Overall av 1.4 per script Av of 1.5 when screened on ward Av of 0.9 when screened in the dispensary Av 1.5 per nonelective script Av 1.2 per elective script Av of 1.4 whether handwritten, fully electronic or electronic from handwritten script

Graphical representation of contributions: all data

Table of contributions by care area

Acute results Top row (L to R) med/surg; Bottom row (L to R): paed/all

Contributions for CHS & MH scripts Top row (L to R) CHS, MH; Bottom row all data

Clinical impact of contributions-all data 33% of overall contributions, approx 1 in 2 scripts affected

Level 3&4 contributions by type of prescription & admission

Does pharmacy-led medicines reconciliation help? 20% scripts had no pMR (NB: 80% had had pMR) 56%: (A) pMR helped ensure discharge summary appropriate 15%: (B) pMR helped identify a problem needing resolution 8%: (C) pMR helped identify AND resolve a problem without need to contact prescriber In 23% pMR directly improved accuracy of medication at discharge

Average number of prescribed items

Average time for clinical screen by care area

Average time for problem resolution by care area

Proportion of scripts screened by pharmacy (with caveats!!) Asked for organisations to interrogate PAS data to establish the number of discharges for the ward areas audited Data returned from 36 organisations Many problems in getting correct number of discharges over allotted period- some uncertainty around data For 1730 scripts reviewed, 3129 discharges recorded Overall, it appears approx 55% of discharge prescriptions are actually seen by pharmacy depts

Summary Still much analysis to be done! Pharmacy contributions contribute significantly to safe and accurate discharge information Cost avoidance calculations will be attempted! Data highlight areas where prescribers need to improve E&T support from pharmacy? Data illustrate added value of pMR (safety/time saving) Is there any improvement in accuracy from all electronic prescribing? Are the timings recorded accurate? What about all those UNSCREENED prescriptions….?

Thank you! Steering group Participating organisations Christine Masterson Martin Webb & Liz Gull Questions?