Common Trapswith

Sources for Medication HistoriesThanks to the Pharmacy Department for their numerous suggestions

August 2011

Objectives

• To be aware of some advantages and disadvantages of various BPMH sources

• To be able to avoid common BPMH traps where interventions are often subsequently made

General Practitioners/Specialists

Referral letter with list often accompanies patient Administration officers can phone & fax request Useful for confirming details eg strengths What the GP believes the patient takes Often incomplete/not up-to-date

Not necessarily updated/deleted Often no directions: ‘MDU’ Generally records of only 1 GP Doesn’t include OTCs/CAMs/non-Rx/specialists

Often need to cross-reference with patient

GP List:Just 1 of 3 pages

Community Pharmacies

• Dispensing historiesAdministration Officers can phone & fax requestMost Redland patients only use one pharmacyWill have information about dispensed items additional

to a Webster packCompliance: regularity of dispensing, items dispensed May not be complete (other pharmacies, GP samples) Rx and S4 (label required) items only Need to go back in time eg digoxin comes in bottles of

200: may not have dispensed for 7 months

Community nurse & Patient lists

A list from the ‘source’ (patient/carer)Generally kept up-to-date by patient/carerMay only consist of ‘prescribed

medications’/those deemed ‘important’Often inaccurate/incomplete/missing doses

• Ensure still up-to-date and fully complete• Still need to ask other specific questions

eg puffers, patches, eye drops, CAMs…

Previous Admission All QH admissions easily accessible via eLMS

…presuming that nothing has changed Verbal changes to discharge medications not communicated

to Pharmacy no changes made to eLMS Patient ceases items due to

misunderstanding/dislike/cost/exhausted discharge supply etc GP ceases items Items added by patient/GP/specialist/OPD clinic Prescribing/dispensing/administration errors

List may not have been complete on last admission Up to 17% of items may be incorrect Ensure still up-to-date and fully complete

The DMR is usually out-of-date the moment the patient leaves MUST use as a BASELINE list to build upon

• Charted amiodarone 200mg daily, but according to DMR from 5 days ago, should still be being loaded with 200mg bd for 5 more days

Previous D/C (11/2010) Current admission (5/2011)

Thyroxine 125mcg m Thyroxine 125mcg m

Omeprazole 20mg m Omeprazole 20mg m

Aspirin 100mg m Asprin 100mg m

Frusemide 60mg mmid Frusemide 80mg m

ISMN SR 120mg m ISMN SR 120mg n

Coloxyl & Senna 2 bd Coloxyl & Senna 2-4 n

Paracetamol 1g tds Paracetamol 1g qid

Cholecalciferol 25mcg m Cholecalciferol 25mcg m

Temazepam 10mg prn Temazepam 10mg n

Escitalopram 20mg m Citalopram 20mg n

OxyContin 20mg bd OxyContin 5mg bd

Metoprolol 25mg m Carvedilol 6.25mg bd

Span K 600mg m

Charted on admission

Residential care facility

Should be an accurate representation of ALL medications NB Check for the RIGHT PATIENT!

ED pharmacist often notes the wrong chart has been sent

Directions can be ambiguous Check for ‘cease date’ – order not necessarily crossed out Chart may not be most recent orders

Check dates RNs may give doses from a range eg ‘0-40mg’

Look at nurse administration section More than 1 page of medication list

Check for eg ‘2 of 2’ May not correspond with community pharmacy supplies

Good practice to also request community pharmacy list Community pharmacy details located on NH medication charts

Mismatch between NH Chart and Packed Medications

Look for STOP DATES!

Looks as though still prescribed

The need for the second source

• Looks like ‘100 1 bd’ - Charted on admission

• Was originally ‘10mg bd’

• Patient actually NO LONGER TAKING - (see cease date)

• Phone call to community pharmacy confirmed this

Patient’s Own Medications

• DO NOT send home with carer– Often need to refer back to them during admission

Many details immediately evident Drug/strength/dose Compliance - # of tablets left vs dispensing dates vs expiry dates GP/community pharmacy information Taking other people’s medications/dispensing errors

Instructions may be out-of-date (refills of old Rx) Patient may have brought in other people’s medication

CHECK NAME carefully & confirm with patient that still taking Patient may not bring in all items eg if stored in the fridge Contents may not match packaging eg halved tablets

MUST look inside the bottle

Colour-blind?

• ED pharmacist asked to review the medications for a warfarin pt with an INR>10

• Warfarin started approx 10 days ago, advised to take 2mg daily– pt confirmed that he takes 2 brown Marevan tablets daily

• Vit K administered, pt to return next day for another INR• Pharmacist asked pt to bring all his medications the next

day for review

• The bottle containing 1mg tablets was still sealed and pt was actually taking 2 pink (5mg) tablets daily

Webster packs

• Can be a double-edged sword Back of pack may not match contents Patient may not take all of contents eg frusemide Patient may take additional items

eg warfarin, patches, puffers, injections Some Webster’s wording groups multiple medications

with the same strength togethere.g. aspirin/allopurinol 100mg mane, instead of creating 2 separate entries for each drug

The danger of Webster packs

Webster Pack BPMH

Quinapril 10mg m

(NB back of pack states: 20mg)

Quinapril 10mg m

Frusemide 40mg mmid Frusemide 40mg mmid

Paracetamol 1g qid Paracetamol 1g qid

Coloxyl & Senna 1 n Coloxyl & Senna 1 n

Metformin 500mg bd Metformin 500mg bd

Seretide 250/25 2 bd

Lantus 14 units n

Panadeine Ft prn

WARFARIN

Implies daily dosing

Actual dose = Tues & Fri only

Front of pack often (BUT NOT ALWAYS) has ‘strange’ doses listed eg bisphosphonates/non-packed items

Count the tablets

Call the community pharmacy

Can also need to check what’s not packed

Patients/carers Best when patient’s own medicines are present Ask open-ended questions Specifically ask about: (see MAP checklist)

INJECTIONS: Insulin has been previously missed Patches/creams/eye drops/inhalers Once a week/month CAMs Non-Rx items…

Patients may not realise the importance of non-tablets Some patients have filled new prescriptions but not

actually started taking

Wording: what’s wrong with this picture?

• ‘What tablets do you take at home?’• ‘Avapro – 1 tablet in the morning, right?’• ‘Can you please list your medicines for me?’• ‘This is what I’m supposed to take…’

• ‘What are you allergic to?’

Thank you!

Questions