Safe and Effective Prescribing

2014

Pharmacy Department

Policies and guidance relating to medicines

• Policy on Governance Arrangements relating to Medicines• Medicines Policy• Procedure for allergies, idiosyncrasies to medicines and food• Delayed and omitted doses of medicines• Policy for medicines reconciliation on admission of adults to

hospital• Rules relating to all activities involving CDs• Guidelines for patient self-administration of medicines• Antimicrobial policy• Anticoagulation guidelines

Medication Practice CommitteeMedicines Management Policy setting group

Cornwall Area Prescribing CommitteeFormulary and Clinical Guidelines Group

Medication Safety GroupReview and learning from datix etc

Committees

The Medicines PolicySafe, standardised and secure method of handling medicines

You need to know your responsibilities around medicines

• Prescribing

• Ordering

• Preparation and administration

AllergyProcedure for allergies, idiosyncrasies to medicines and food

• Every patient needs a documented allergy status• JAC has a NKDA button• No patient should be prescribed, supplied or administered

without being complete – including outpatient prescriptions• Re-confirm on each admission

Allergy - Errors

• Since the implementation of EPMA we have had 2 incidents of patients receiving medicines that they are allergic to

•Patient was documented as allergic to tramadol on EPMA and the prescriber overrode the warning to continue to

prescribe it.

•NKDA was entered incorrectly onto EPMA, as the patient was allergic to penicillin. They were prescribed penicillin and developed a rash.

Missed dosesDelayed and omitted doses of medicines

• Reasons have to be entered on to EPMA for any missed doses• Prescribers must be alerted after missing 1 dose of a critical medicine

or 2 doses of any other medicine• Critical medicines should not be omitted

Antibiotics, Antifungals, AntiviralsAnticoagulantsImmunosuppressantsParkinson’sAnti-epileptic medicationsInsulinResus medicinesDesmopressin

• Missed doses report sent to wards and pharmacists

Missed Doses of Desmopressin• Patient with diabetes insipidus admitted without her

desmopressin tablets• Next morning, ordered by nurses but non-stock order form

lost – ?never reached pharmacy• Following morning ordered again and supplied, but patient

had already missed 48 hours• Patient hypernatraemic, vigorous rehydration but

deteriorated and died

Medicines Reconciliation“A complete list of medicines, accurately communicated”

• An up to date and accurate list of medicines that patients were taking prior to admission

• Documenting any discrepancies, changes, deletions and additions

Medicines Reconciliation - errorPatient with lupus and lung disease on an increasing dose of mycophenolate mofetil and was written up for both doses of (both 750mg bd and the next dose increase 1g bd).

Medication was transcribed from printed list sent from GP surgery without checking BNF, checking patients current drug packets or asking patients wife (who had sheet stating exactly what dose should be taken) what dose of mycophenolate was appropriate.

This resulted in an overdose

Antibiotics

• Antibiotic stewardship protocol – to reduce inappropriate antibiotic use

• Start SMART then focus• Must follow Trust guidelines• Ensure review dates especially for Tazocin• Include indication and Stop/review date• Restricted list or not as per policy need micro approval

and a documented code• Right antibiotic/Right time• Antibiotic webpage and new app

Antimicrobials –do not delay

• Patients with sepsis must have the first dose prescribed and administered within one hour

• How to obtain restricted antibiotics

AnticoagulationThrombosis prevention, investigation and management of

anticoagulation guidance

• Our Trust uses dalteparin as LMWH• VTE risk assessment must be completed – part of

JAC• Weigh the patient for treatment doses• ACS policy – fondaparinux and ticagrelor• Rivaroxaban/dabigatran/apixaban - care on

admission

Insulin

• All patients should have an insulin passport

• Patients should be assessed for the self-administration of insulin

• 4 Trusts in the SW have recently had incidents with insulin for hyperkalaemia

Controlled Drugs Rules relating to all activities involving CDs

Ward, Theatre and department SOPs for CDs

• Accountable Officer – Andrew MacCallum (Director of Nursing)

• Procedures

• Usage monitored

• CQC registration and NHSLA

Pharmacy: Sources of advice• Ward pharmacist• Medicines Information x2587• Hospital protocols - intranet link Quick Links : clinical

guidelines• Antibiotic Policy• BNF• Smart apps (Athens log-in)

ReportingMedication error reporting

• DATIX system• we try to learn from errors• Medicines Safety Group review trends

Adverse Drug Reaction reporting• Use MHRA yellow cards when appropriate, as well as DATIX

Other policies• Injectable Medicines Policy• Policy for patient self-administration of medication by

competent patients• Non-medical prescribing Strategy

E-prescribing within RCH

Paperless prescribing and medicines administration A major investment by the trust in patient safety

A key step in the move to a complete electronic patient record for new patients by 2015.

Immediate benefits to staff• Legible prescriptions

• Remote prescribing

• No more chart re-writes

• No more looking for charts

• Information about the drugs at the point of administration

• No more drug charts to pharmacy

• Clear signatures for prescriptions and administrations

• Administration information from previous stays available at any time

Lots of information at your fingertips!

The benefits so far…

• The trust now scores 100% for allergy documentation• Prescribers no longer have to re-write drug charts or

transcribe TTAs, one of the high risk prescribing activity's• Restricted prescribing by role e.g. nurses can only

prescribe set homely remedies• Remote prescribing cuts down night time floor walk

Benefits to us all!

• Patient safety improvement

• Quicker TTOs and Non-stock drugs

• Releases time to care