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Care homes medicines champions workshop
North East Essex CCG Medicines Management Team Sarah Westall, Carol Sampson, Lisa Stephenson Essex County Council – Prosper Lesley Cruickshank, Kieran Attreed-James
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The unintended consequences of medicines
Between 5 to 8% of all unplanned hospital admissions are due to issues related to medicines (this figure rises to 17% in the over 65s) At least 6% of emergency re-admissions are caused by avoidable adverse reactions to medicines When admitted to hospital most patients have a medicine omitted or a wrong dose recorded. Patients taking several medicines for long term conditions are most likely to have errors .
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The unintended consequences of medicines
Poor communication of information at transition points is responsible for as many as 50% of all medication errors ……and up to 20% of adverse drug events in hospital A DH funded study (CHUMS):high prevalence of errors in medicines 7 out of 10 experience a medication error ( average 85yr taking 8 medications)
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CCG website – Care Homes
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Patches Name Frequency Application Site interval Fencino (Fentanyl)
72hrs A new skin area must be selected for each application however an area of skin can be used again if a 7-day interval is observed since the removal of the last transdermal patch. 7 days Scopaderm (Hyoscine) 72hrs protection The patch should be placed onto a clean, dry, hairless area of skin behind the ear, taking care to avoid any cuts or irritation. A fresh patch can be applied behind the other ear after 72 hours 3 days Butrans (Fentanyl) Stick a new patch on a different appropriate skin site. You should not apply a new patch to the same site for 3-4 weeks 21-28 days Neupro (Rotigotine) 24hrs Put the patch on a different area of skin every day, and only use the same area again after 14 days 14 days Durogesic A new patch should be applied to a different skin site after removal of the previous transdermal patch. Several days should elapse before a new patch is applied to the same area of skin Transtec 96hrs Stick a new transdermal patch on a different skin site. Wait at least one week before using the same site again.
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High risk drugs Warfarin Be familiar with different colours of
various strengths Administer from original packs Service users have copy of “yellow book” Warfarin dosages confirmed by prescribers in writing/fax. Always cross reference MAR chart, dose confirmation and fax before administering and get a witness to double check Recording on the MAR sheet How to manage missed doses
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Week 1 1st January 2016 Week 2 Week 3 Week 4 Commencing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Medication Dose time Warfarin tablets 1mg Take as directed morning lunch tea night Sig Quantity 28 Date Balance carried forward returned Commenced Route O Warfarin tablets 3mg Date Balance carried forward returned Commenced Warfarin tablets 0.5mg Quantity 28 Commenced Route Oral
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Bill Week 1 1st January 2016 Week 2 Week 3 Week 4 Commencing 1 2 3 4 5
Week 1 1st January 2016 Week 2 Week 3 Week 4 Commencing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Medication Dose time Warfarin tablets 1mg Take as directed morning lunch tea night Sig Quantity 28 Date Balance carried forward returned Commenced Route O Warfarin tablets 3mg Date Balance carried forward returned Commenced Warfarin tablets 0.5mg x Quantity 28 Commenced Route Oral
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Gladys Week 1 1st January 2016 Week 2 Week 3 Week 4 Commencing 1 2 3 4
Week 1 1st January 2016 Week 2 Week 3 Week 4 Commencing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Medication Dose time Warfarin tablets 1mg Take as directed morning lunch tea night Sig Quantity 28 Date Balance carried forward returned Commenced Route O Warfarin tablets 3mg Date Balance carried forward returned Commenced Warfarin tablets 0.5mg x Quantity 28 Commenced Route Oral
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Methotrexate Folic Acid Administer from original packs
Reduces side effects Not to be taken on same day as Methotrexate Administer from original packs Dose should be dispensed as 2.5mg tablets Weekly dose Service users have copy of “methotrexate book” Always cross reference MAR chart, dose Record on the MAR sheet How to manage missed doses
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Lithium NPSA alert Dec 2009 ‘Some patients taking lithium have been harmed because they have not had their dosage adjusted based on recommended regular blood tests’ There must be effective communication between all healthcare practitioners involved with patients on lithium therapy Medicines such as ACEi, thiazide diuretics, non-steroidal anti-inflammatory drugs and sodium containing antacids, affect kidney function and lithium excretion. Unless lithium levels are monitored and the dose adjusted, concomitant use may cause lithium toxicity or with sodium containing antacids sub-therapeutic levels.
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MISSED DOSES Delayed or interrupted treatment could make a person ill or delay recovery Always: Refer to the GP for medical advice Ways to reduce missed doses: Talk to the pharmacist about whether the regimen can be changed or timings of doses Distribute fresh water before medication round Avoid interruptions – Do not disturb Identification of residents Maintain stock levels of ‘as required’ medicines Correct timing of medication Printed MAR charts Follow the 5 R’s What if the resident refuses the medication?
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ALLERGY STATUS. WHAT REACTION DO THEY GET
ALLERGY STATUS! WHAT REACTION DO THEY GET? WHAT IF THEY HAD AN ALLERGY TO PENICILLIN? INSTRUCTIONS MISSING, INCORRECT TIME & SHOULD BE ON THE SAME DAY EACH WEEK SIGN VARIABLE DOSE SHOULD STATE THE NUMBER GIVEN SIGN ASK GP TO REVIEW IF NOT REQUIRED. WHEN REQUIRED DOSES SHOULD HAVE A PRN POLICY SIGN STRENGTH/FORMULATION/ GAPS & PATIENT REFUSED. HOW DO WE HANDLE REFUSAL OF DOSES? SIGN SO HOW DID YOU GET ON? SIGN SAME DRUG BUT WRITTEN IN BOTH THE BRAND & GENERIC FORM. PATIENT HAS THEREFORE HAD FOUR PUFFS INSTEAD OF TWO? SIGN
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Expiry date guidelines
Tablets and Capsules - Blister/foil packed (NOT MDS) Manufacturers Expiry Date Tablets and Capsules (Loose) One year from date of opening, or manufacturers recommendation where shorter Tablets (Effervescent) 1 month if removed from original container Liquids (External) Six months from date of opening, or manufacturers recommendation where shorter Liquids (Internal) Exceptions: Appendix 1 Three months from date of opening or manufacturers recommendation where shorter (record date when opened) Ointments/creams (In tubes) Six months from opening or manufacturers recommendation if shorter (in pots) Three months from opening or manufacturers recommendation if shorter Inhalers Manufactures recommendation/ refer to dose counter Suppositories/pessaries Manufacturers recommendation Sterile products Ear Drops Manufacturers recommendation and discard one month after opening Eye drops and Eye Ointment Injections Exceptions: Insulin Manufacturers recommendation and discard immediately after use One month after opening
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Additional Expiry date guidelines
APPENDIX 1 Persantin Retard (Dipyridamole SR) 6 weeks after opening original dispensing container. Once capsules are packed down into another container then 4 weeks expiry Glyceryl Trinitrate tablets 8 weeks after opening Madopar capsules and tablets 2 weeks when dispensed into another container Nicorandil Manufacturer recommendation, then once opened each blister has a 30-day expiry. Use each blister strip at a time before opening the next. The blister strip contains a drying agent to protect the tablets from moisture which should NOT be removed or swallowed. Antibiotic liquid Usually 7 or 14 days when freshly prepared. See label on preparation Optive Eye drops 6 months after opening Insulin Manufacturers guidelines when stored in a fridge between 2ºC and 8ºC. When in use can be kept at room temperature (25ºC) for 1 month Manufacturers Expiry Dates ‘Use by January 2015’ Discard by 31/12/2014 ‘Discard after January 2015’ Discard 31/01/2015 ‘Expires January 2015’ Use within one month of opening Self-explanatory
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PRN ‘WHEN REQUIRED’ & VARIABLE DOSES
GOOD PRACTICE Clear and specific labelling Take one to two tablets every four to six hours when required, up to a maximum of 8 tablets in 24 hours to relieve back pain Care plan/PRN protocol clear HOLLISTIC treatment and outcome plan (consider using template) Details of what the medication is being used for /symptoms /can resident ask for it When to refer to the GP/ maximum dose Stock levels boxed / kept in original packaging with the pharmacy label on it ‘carried forward’ from one month to the next Homely Remedies Administration of VARIABLE DOSES how a decision is made on the dose to administer (e.g. 1 or 2 tablets) Medication Administration Record (MAR) Number of tablets / dose administered, especially where there is a varying dose (e.g. 1-2 tablets)
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Homely Remedies/Self Care
NEECCG policy Do you have a homely remedy policy? Your pharmacist can advise Self care policy NEECCG has a policy whereby patients should purchase certain medications themselves Residents in care homes should have access to medications for minor ailments Self care unless they have a recognised long-term condition Homely remedies ‘sample’ policy. Use with community pharmacy
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Examples of ‘specials’
Ibuprofen 400mg capsules x 84 £704.42 £70.42 £7.42 Captopril Liquid Special 25mg/5mls £50 to £1,556 for the same medicine Cetirizine 1mg/ml SF, LF, sorbitol free 200ml £389.20
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DRUGS USED COMMONLY IN CARE HOMES
Common side - effects DRUGS USED COMMONLY IN CARE HOMES DRUG INDICATION COMMON SIDE EFFECTS Alendronic acid Bone Health Throat irritation, abdominal pain Amlodipine Blood Pressure Headache, feeling dizzy or tired Atorvastatin High Cholesterol Muscle aches, pains Beclomethasone Breathing problems Sore throat, thrush Bendroflumethiazide Water retention or blood pressure Feeling dizzy (especially when you stand up due to low blood pressure) Calcium & Ergocalciferol Unlikely to cause any side effects Co-codamol Pain Relief Feeling or being sick, constipation, feeling sleepy Finasteride Prostrate Reduced desire to have sex Furosemide Feeling dizzy, particularly when you stand up (due to low blood pressure) Lactulose Treatment of constipation Excess wind, abdominal discomfort Loperamide Treatment of diarrhoea Constipation, wind Macrogol Abdominal pain, flatulence Paracetamol Mild to moderate pain, fever Salbutamol Feeling shaky Senna Stomach pain or cramp, diarrhoea Simvastatin High cholesterol Muscle cramp, pain or tenderness Spiriva Dry mouth Tamsulosin Feeling dizzy, ejaculation problems Temazepam Sleep aid Feeling drowsy or dizzy, blurred vision. Feeling unsteady, confused or forgetful Tramadol Pain relief Feeling dizzy, tired or sleepy, feeling or being sick, constipation, dry mouth Warfarin Blood thinning Unusual bleeding or bruising Zopiclone Feeling sleepy or tired. A bitter or metallic aftertaste, dry mouth References: ■BNF Online ■Product SPCs - ■Patient.co.uk
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Must inform DN’s so stock can be replenished Complete the form
5 Dressings in a Bag? Must inform DN’s so stock can be replenished Complete the form Contact details; Colchester Tendring
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Repeat prescriptions, prescription ordering
Opportunity for wasted medicines & overstocking Good stock control, carried forwards & balance control Take ownership, your responsibility Keep records of all orders Follow up out of stocks
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