Medication Safety and admissions avoidance: A

perspective

Steve Williams Consultant Pharmacist in

Medicine & Medication Safety

Honorary Clinical Lecturer, Manchester Pharmacy School

June 2015

Outline for Session

– How big is the issue?– Is the situation getting better or worse?– Does the NHS take Medication Review

seriously enough?– What should we all be doing about it ?

How many non elective admissions to English hospitals every year are due to medicines?

– Think of a number…..

Important academic references

– 11.2% patients had adverse drug events (ADEs) causing hospital admission (47.6% preventable)

– Patient age , time since starting new medicine and total number of medicines independently predictors of admission

– Antiplatelets, anticoagulants , diuretics, ACE inhibitors and anti – epileptics major culprits

Kongkaew, C., Hann, M., Mandal, J., Williams, SD, Metcalfe, D., Noyce, P. & Ashcroft, D. Risk Factors for

Hospital Admissions Associated with Adverse Drug Events. Pharmacotherapy 2013; 33: 827-837

Important academic references

– 6.5% UK hospital patients admitted due to Adverse Drug Reactions (ADRs)

(72% preventable) Pirmohamed et al BMJ 2004;329:15-19

– Preventable drug related problems accounted for 3.7% of hospital admissions. Antiplatelets, Diuretics, NSAID’s accounted for 50% of all admissions

Howard et al BJCP 2007;63:136-4

– 20.8% patients readmitted to hospital due to ADR within 1 year of first admission.

Diuretics & Antiplatelets most frequent culprits Davies EC et al BJCP 2010;70:749-55

BUT under recognised because under reported ?

– International Classification of Disease (ICD) coding from hospital databases are not reliable for identifying ADRs Hohl CM,Karpov A, Reddekopp Let al. ICD-10 codes used to identify

adverse drug events in administrative data: a systematic review J Am Med Inform Assoc 2014;21:547–557

– Only 9% of adult patients admitted to a UK hospital with a confirmed medication related harm (ADRs , medication errors, non-adherence) had a related ICD code documented. Reynolds M et al. A

descriptive exploratory study of how admissions caused by medication-related harm are documented within inpatients’ medical records. BMC Health Service Research 2014; 14: 257

– Hohl CM,Karpov A, Reddekopp Let al. ICD-10 codes used to identify adverse drug events in administrative data: a

systematic review J Am Med Inform Assoc 2014;21:547–557

BUT under recognised because under reported ? (2)

– 31.5% of children admitted to a UK hospital with a confirmed ADR had a related ICD code documented Bellis et al. BMC Pharmacology and Toxicology 2014, 15:72.

Clinical coding of prospectively identified paediatric adverse drug reactions – a retrospective review of patient records

And the situation is only getting (and will get even) worse

Polypharmacy meets Multi-morbidity

Does the NHS take Medication Review seriously enough?

We have some evidence

And there are plenty of tools to help

– NICE Medicines Optimisation guidance – Kings Fund , Scottish and Welsh

Polypharmacy documents (CPPE focus too 2016)

– Seven steps to managing polypharmacy: Specialist pharmacy Services document

– Reducing Inappropriate Polypharmacy: The Process of Deprescribing Scott IA et al JAMA Intern Med 2015.

doi:10.1001/jamainternmed.2015.0324

– STOPP START Gallagher P et al Int J Clin Pharmacol Thera 2008;46:72-83

– No Tears Using the NO TEARS tool for medication review. T Lewis. BMJ 2004;329:434

Does the NHS take Medication Review seriously enough?

Can we compare it with a routine Total Knee Replacement (TKR) ?

Total Knee Replacement

– Preoperatively (50 mins)

– Preop assessment clinic (30 minutes Nurse + 20 minutes Doctor)

– Tests: ECG, bloods, and MRSA swabs

– Consent form 

– Day of Surgery (150mins)– Anaesthetic pre-op

assessment (10 min) – Anaesthesia-spinal or GA

(20 min) Anaesthetist plus ODP or nurse

– Surgery (90mins) 2 scrub nurses, 2 surgeons,1 anaesthetist, 1 runner

Total Knee Replacement (2)

– Post operatively– Recovery (60 mins)

1 Anaesthetic nurse– 3-4 days on ward,

OT and PT twice a day

– Post discharge – Continue physiotherapy for

several weeks individually in a group depending on the patients needs

– Follow up clinic appt with doctor

A typical Medication Review?

– Play video

A typical Medication Review?

– 1 GP (10 mins)

Does the NHS take Medication Review seriously enough?

– Fail to plan , plan to fail!

So what could the NHS be doing about it ?

Thomas J. A multidisciplinary approach to reducing avoidable medication-related harm/hospital admissions. Clinical Leadership Conference 2013. www.learningwales.tv/group_items/view/1354

2020: NHSE Medicines Optimisation Dashboard to include Medication related admissions per CCG ?

2020: NHSE Medicines Optimisation Dashboard to include Medication related admissions per CCG ?

– But it is going to need some levers

But finally what could YOU be doing about it ?

Is balancing the Prescription Equation your key to medication related admissions avoidance?

“If we just keep adding, and not subtracting, we just multiply the medication problems”

Thanks for listening

– Any questions?