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WHO The Third Global Patient Safety Challenge
Medication Without Harm
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“Reduce the level of severe avoidable harm related to medicines by 50%
over 5 years globally”
Jean Day and Tania Xavier Medicines Optimisation Pharmacy Technician
Guys and St Thomas NHS Trust
Objectives of the Global Challenge on Medication Safety
1. ASSESS the scope and nature of avoidable harm and strengthen the monitoring systems to detect and track this harm
2. CREATE a framework for action aimed at patients, healthcare professionals and member states, to facilitate improvements in ordering, prescribing, preparation, dispensing, administration and monitoring practices, which can be adopted and adapted by member states.
3. DEVELOP guidance, materials, technologies and tools to support the setting up of safer medication use systems for reducing medication errors.
4. ENGAGE key stakeholders, partners and industry to raise awareness of the problem and actively purse efforts to improve medication safety.
5. EMPOWER patients, families and their carers to become actively involved and engaged in treatment or care decisions, ask questions, spot errors and effectively manage their medications.
THE KEY ACTION AREAS Early priority action is to protect patients from
harm arising from 3 key areas 1. High risk situations 2. Polypharmacy
3. Transitions of care
Transitions of care
“Transitions of care increase the possibility of communication errors. Patients are at
increased risk during transitions of care and so serious mistakes can and do occur at these
times, in particular ” “WHO the third global patient safety challenge medication without harm”
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Key aspects of safety during ToC
30-70% of patients have an error or unintentional change on admission*
11-34% of patients receive inadequate information about medicines post discharge.***
• *NSPA& NICE 2007 • **IJCP 2004 • *** AJHST 2012 • # howard R, Avery A & Bissel P • #* N.parekh et al.
Communica)on failures between prac))oners , prac))oners and their pa)ents as well as gaps in pa)ents medical and drug histories can lead to preventable drug related admissions at various stages of the medicines pathway #
Older adults are vulnerable to
medica)on –related harm problems during transi)ons of care from hospital into community#*
60% of pa)ents have more than 3 changes to their medica)on during a hospital stay.**
“When taking over the care of a pa)ent the healthcare professional responsible should check that informa)on about the pa)ent’s medicines has been accurately received, recorded and acted upon” (RPS keeping pa)ents safe 2011)
Services aim to avoid hospital admissions & facilitate early discharge from, by providing , social care, OT
equipment and physiotherapy. • Enhanced rapid response team • Supported discharge teams • Urgent response team • Rehab and Reablement teams • Patients stay up to 6wks. • Pharm tech – patient facing role • Staff enabling role- incl. Training to undertake meds
related tasks, advice and support
Pharmacy technician role in adult community reablement services
Transitions of care within Reablement teams
• Medications are involved in every transfer of care. • Medicines reconciliation • Done as part of initial assessment
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Reablement Team
Pharmacy team devise and deliver a robust training programme for therapists
>180 staff Trained to undertake med rec since March 2017
Train the trainer : Nurse attend training to enable them to assess competency for therapists
Therapists attend meds rec training and complete the competency framework
Once signed off as competent therapist carry out meds rec as part of initial assessment when the patient enters the service (usually within 24 hours )
Therapists have access to pharmacy staff for queries when completing meds rec in the patients home , to make the patient safe. They can then refer to Pharmacy for more complex issues
Reported Medication Errors (datix) in reablement services before and after improved training
0
10
20
30
40
50
60
70
80
90
100
2017
total da)x med rec da)x
2018
>4500 pa)ents seen by the GSTT reablement services last year
1 in 3 older adults will have medicines related harm post discharge PRIME study N.Parekh et al 2018
That is ~ 1,500 of pa<ents seen by reablement service.
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> 180 therapists trained to do medicines reconcilia)on since 2017
Medicines reconcilia)on completed within 24 of referral ( usually within 2-‐4 hours)
166 Reported medica)on errors in the services since Nov 2017, 74 were for med rec errors
Case example. Error identified during meds reconciliation and resolved
Case example – reducing risk from non adherence
• Parkinson’s patient • Therapist conducts medicines rec. • Dosing of medication 6 times a day • Patient has blister pack with all medication listed as being in the pack.(blister pack only
has QDS compartments) • Therapist notices that co-carldopa dose TDS (no tablets in the blister pack are TDS) • Refers to MOPT for advice. • MOPT visits patient to check meds and look at care agency MAR chart and carers notes • 11am dose should have been supplied in original pack for carer to leave out at 8am for
pt to take at 11amðClearly stated in care planð No supply at patient’s propertyð Patient not getting mid morning dose for several weeksðsuffering severe PD symptoms
• MOPT Contacts community pharmacy to arrange supply and delivery ASAP, informs the carer and care agency.
• The patients got his mid morning dose the next day and he reported a great improvement in his symptoms.
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Case example: reducing harm from ‘high risk drug’ • Therapist conducts med rec • Notices that patient has warfarin on GP summary, which is
being administered by carer • Daltaparin started in hospital and being administered by
district nurses. • Therapist contacts ERR pharmacist for advice.
Top tips
Engage : educate therapist about the importance of their role in reducing the risk of medica)on harm to the pa)ent including non
adherence. Through medicines reconcilia)on.
Enable: through robust training 3 C’s of medicines reconcilia)on
THE KEY ACTION AREAS Early priority action is to protect patients from
harm arising from 3 key areas 1. High risk situations
2. Polypharmacy 3. Transitions of care
Medicines Optimisation pharmacy technician role in District nursing service
• The district nursing service provides nursing care in the home to adults >16: housebound, unable to care for themselves/FRAIL
• Help & support patients towards independence in managing their care needs and LTCs
• Patient facing role-domicilliary visits
• Lead on medicines optimisation incl reducing meds related risks
• Provide medicines training to staff • Support/ advice on safe handling/
administration of medicines and queries
• Safety and Governance • Pharmacy Team Lead for sensory
impairment
Referral from GSTT District
Nurses service
Background
Person centred consultation
Goals/outcomes agreed with
patient
Liaise with MDT as necessary
Monitor patient
Safety briefing, case load reviews, datix investigations, triage
Reason for referral, SCR, LCR, EPR, assessment, Carenotes
BP, training support, observation, coaching, assessing risk of interactions and adverse effects
Engage with all practitioners involved
Goal setting, med rec
Support views/ decision making, clarify concerns and beliefs
Pathway to pharmacy for patients on DN team caseload
0 100 200 300 400 500 600
DN/ specialist nurse
OT/ Physiotherapist/therapist
GP/Dr
ICP pharmacist
Consultant
community matron
Practice Pharmacist
hospital pharmacist
Community pharmacist
social worker / stroke advisor
ICP technician
Practice nurse
Patient self referral
Physicians associate
Number of referrals by Practitioner Oct 2016 to Apr 2018 (No 1411)
April 2018 to September 2018 Number of Home visits 264 Non-home visit interventions 106 Number of training sessions 111 Clinical meetings attended 230 (CMDT, Safety Briefing, Case conferences)
Managing Polypharmacy • Evaluate how the patient manages to take medicines • Being alert to unexpected interactions, and effects of
medicines • Provide written materials for patients, that complement PIL e.g.
larger print, good colour contrast for people with poor vision • Verify that the patient understands and agrees to the regimen • Advise on lifestyle changes • During acute illness, older people may experience temporary
cognitive problems, and may need extra support from nurses/carers. Pharmacy tech provides advice Recognise own scope and competencies and liaise with
pharmacist within team
Case example, Mr A, 81yo
• Reason for referral: Polypharmacy with high frequency administration + newly diagnosed Dementia (forgetting to take medication) & depression
Past medical Hx: • Non-insulin dependent diabetes
mellitus • Hypertensive disease • Pure hypercholesterolaemia • Ischaemic heart disease • Osteoarthritis, DVT • Asthma 1940
1. Amitriptyline 10mg ON 2. Candesartan 8mg OM 3. Amlodipine 10mg OM 4. Bendroflumethiazide 2.5mg OM 5. Metformin 1g BD 6. Ferrous Sulphate 200mg TD 7. Lansoprazole 15mg Oro OM 8. Aspirin tablets 75mg OM 9. Quinine Sulphate 300mg OM 10. Atorvastatin 20mg ON 11. Fultium Vit D 20,000u mthly 12. Dermol cream prn 13. Seretide 125 Evohaler TT BD 14. Salamol 100mcg/Easibreathe
8 weeks later • With pharmacist input, deprescribed medicines • Reduced to 9 tablets daily-once a day administration • No inhalers and cream. • BP stable. • POC in place to support him all meds om. 1. Amlodipine 10mg OM 2. Sertraline 50mg OM 3. Metformin 2g m/r OM 4. Fultium-D3 3,200unit capsules Weekly 5. Ferrous fumarate 322mg tablets OM 6. Aspirin tablets 75mg OM 7. Lansoprazole 15mg OM