NIMC (clozapine titration)

Presented by __________________

Facility/Unit____________________

Prepared by the Australian Commission on Safety and Quality in Health Care

NIMC (clozapine titration)

Background– A 2011 national survey of National Inpatient Medication Chart (NIMC) users in

psychiatric acute services found that charting clozapine titration was problematic.

– Clozapine titration prescribing was non-standardised and found variously in the Once Only / Variable Dose section and the Regular sections of the NIMC.

– Non-standard practices created increased opportunity for harm to our consumers.

Non-standard charting of clozapine on the NIMC

Non-standard charting of clozapine on the NIMC

Non-standard charting of clozapine on the NIMC Client A

Non-standard charting of clozapine on the NIMC Client B

• A standard national adult clozapine titration chart is intended to:

• improve patient safety by reducing risk of medication error

• assist prescribers, dispensers and administrators with charting clozapine titration on the NIMC

• standardise recording of clozapine titration orders• It incorporates decision support, guidance and checklists• The NIMC (clozapine titration) is based on the Queensland

Health Adult Clozapine Titration Chart which was developed jointly by Medication Services Queensland and Queensland Psychotropic Medication Advisory Group

NIMC (clozapine titration)

National Adult Clozapine Titration Chart

• Ensure facility identification is complete including ward or unit details

• Complete year• Clozapine Patient Number (CPN) must be recorded on the

facility identification space

Facility identification and CPN

• Affix the current patient identification label (with the consumer’s name printed underneath by the first prescriber) to pages 2 and 4.

OR • As a minimum, print legibly the patient’s first and family names,

UR number, address, date of birth and gender written in legible print.

Patient identification

• Note that the patient has a NIMC (clozapine titration) in use by ticking Other in Additional Charts on the patient’s NIMC

• Write Clozapine titration next to the box to alert clinicians that the patient has an additional chart in use for clozapine titration

Cross-referencing with the NIMC

• A space for hand writing patient identification is provided on page 3.

• It is designed for health services that use medication chart scanners.

• Health services that do not use scanners may use the identification space as an additional safety device.

Additional patient identification

• All patients should have details of previous adverse drug reactions (ADRs) recorded on their NIMC (acute) or NIMC (long-stay)

• Attach an ADR sticker to the NIMC (clozapine titration) section provided if the patient has an ADR recorded

• Refer to the NIMC for details of previous ADRs and allergies.

Adverse drug reactions (ADRs)

• A check list of investigations required for clozapine monitoring is provided on page 1.

• These are suggested guidelines only and the treating psychiatrist may request further tests depending on clinical results or local policy.

Clozapine monitoring

• Contact the Clozapine Monitoring Centre for approval• Obtain the Clozapine Patient Number and record it in the

Facility Identification box

Clozapine registration reminder

• Prescriber signature is a legal requirement• Prescriber identification (including contact details) is a safety

requirement

Prescribing

Administration record

• A red coloured square is printed on days 7, 14, 21 and 28 as a reminder that patients require blood or metabolic monitoring on a weekly basis as indicated on the Clozapine Commencement Monitoring: Baseline Measurements section of the chart.

• Additional tests may be indicated by the doctor drawing a darkened line around the day box on the required testing day.

Blood test reminder

• If a dose is missed for greater than 48 hours, a psychiatric review must be performed prior to recommencing clozapine treatment.

• Additional guidance is provided.

Recommencing dosing after an interruption to therapy

• When it is not possible to administer the prescribed clozapine, a reason for not administering code must be recorded and circled.

Reasons for not administering doses

• The chart provides an alert system which gives guidance on whether therapy should be continued or ceased according to the patient’s blood results.

Clozapine blood results monitoring system

• All patients, prescribing doctors, dispensing pharmacists, clozapine coordinators and centres using clozapine must be registered with the Clozapine Patient Monitoring Service (CPMS).

Clozapine pre-commencement guide

• All patients recommencing clozapine following an interruption in treatment must have a pre-treatment blood test. This includes patients with therapy interruptions of less than a week.

Blood test monitoring after an interruption to therapy

• Patients must be kept under close supervision and their vital signs monitored for six hours following the first dose of clozapine.

Nursing observations

• A list of some side effects, as well as the time course and action, has been included on page 4. .

Management of side effects

Questions