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 Controlled Drugs Guidelines for patient self-administration of medicines Antimicrobial policy Anticoagulation guidelines Oxygen policy

Medication Practice Committee Medicines Management Policy setting group Cornwall Area Prescribing Committee Formulary and Clinical Guidelines Group Medication Safety Group Review and learning from datix etc Committees

The Medicines Policy Safe, standardised and secure method of handling medicines You need to know your responsibilities around medicines Prescribing Ordering Preparation and administration

Allergy Procedure for allergies, idiosyncrasies to medicines and food Every patient needs a documented allergy status E-prescribing programme has a ‘NKDA’ (no known drug allergies) 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 e-prescribing (EPMA) we have had less 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 doses Delayed 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, Antivirals Anticoagulants Immunosuppressants Parkinson’s Anti-epileptic medications Insulin Resus medicines Desmopressin 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 - error Patient 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 Include indication and Stop/review date Restricted list or not as per policy need micro approval and a documented code Right antibiotic/Right time VSL#3 probiotics for patients 60yrs + and on high risk antibiotics Antibiotic webpage and smart app

Antimicrobials –do not delay Patients with sepsis must have the first dose prescribed and administered within one hour How to obtain restricted antibiotics

Anticoagulation Thrombosis prevention, investigation and management of anticoagulation guidance Our Trust uses dalteparin as our Low Molecular Weight Heparin (LMWH) Venous thromboembolism (VTE) risk assessment must be completed – part of e-prescribing Weigh the patient for treatment doses Acute Coronary Syndrome 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 Patients should have hypo/hyperglycaemia treatment protocols prescribed Ensure you understand the regimen that has been prescribed for the patient

Insulin Error on Datix Pt with Type 1 Diabetes has been scripted for incorrect insulin. Regular insulin is NovoRapid and pt scripted for TDS Novomix 30 insulin. However pt has been self administrating usual regular insulins but N/Staff have signed to say pt has had Novomix 30 insulin (no self administration of insulin form completed at this time)

Controlled Drugs Rules relating to all activities involving CDs Ward, Theatre and department SOPs for CDs Accountable Officer – Andrew MacCallum 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)

Reporting Medication 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 Reports and ‘technovigilance’ Ensure you have completed your training

Benefits to us all! Patient safety improvement Quicker TTOs and Non-stock drugs Releases time to care