secondary care Flashcards
list medicines where administration should be timely
First doses of injected anti-infectives First doses of injected anticoagulants/ thrombolytics Resuscitation medicines First dose of injected anticonvulsant ‘Stat’ doses of any medicines Insulin Strong analgesics Bronchodilators Glyceryl trinitrate Parkinson’s disease medicines
Causes of omitted or delayed medicines at admission
- Intention to prescribe, but not prescribed
New medicines, or set course
Routine regular medicine
Medicine not available on ward
Medicine not prescribed / delayed prescribing
Medicine not stocked on ward / delay in supply
Non-formulary
Out of hours - Route of administration not available
NBM
No IV access
Unfamiliar preparation, administration, method or
device - Nurse unaware stat dose prescribed
- Patient refused
- Patient not on ward at scheduled administration time
Incomplete or incorrect medication history
Poor communication of medication history on admission
Poor medicines reconciliation process
Clinical judgements based on incomplete, inaccurate, poorly documented or unavailable information may lead to medication errors or adverse events.
Implementing medicines reconciliation at all transitions in care – at admission, transfer and discharge – is an effective strategy for ensuring complete and accurate medication history on admission and preventing adverse drug events.
Any difference between the drug history and the admission prescription chart is known as
medication discrepancy
List examples of an intentional medication medication discrepancy
- starting a medication
- stopping a new medication
- therapeutic substitution
- adjusting dose, form, frequency or route
List examples of unintentional medication discrepancy
- omitting medication
- incorrect medication
- Restarting a discontinued meds
- wrong form, dose, frequency or route
list the contributing factors of medication errors during transfer of care
No access to patient medication list
Transcribing errors in hospital record
Discrepancies between what the patient takes and the medication list
Patient account affected by acute condition
state the four core principles for HCP
HCP ensures all necessary medicines-related information accurately recorded and transferred with patient
HCP taking over care checks medicines-related information has been accurately received, recorded and acted upon.
Patients encouraged to be active partners in managing their medicines when they move – why, when and what medicines.
Medicine-related information should be communicated in a way which is timely, clear, unambiguous and legible
What is medicine reconciliation
The process of identifying the most accurate list of a patient’s current medicines, comparing them to the current prescription chart, and communicating any changes.(NPC)
The process of identifying an accurate list of a person’s current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes, thereby resulting in a complete list of medicines, accurately communicated.(IHI)
State the aim of medicine reconciliation on admission
Aim of medicines reconciliation on admission is to ensure that medicines prescribed correspond with those that the patient was taking before admission.
What is medicine optimization?
the safe and effective use of medicines to enable the best possible outcomes
State the aim of medicine optimization
Aims to ensure that medicines provide the greatest possible benefit to people by encouraging medicines reconciliation, medication review, and the use of patient decision aids.
State how medicine reconciliation should be carried out according to NG5
Recognise that medicines reconciliation may need to be carried out on more than one occasion during a hospital stay – for example, when the person is admitted, transferred between wards or discharged.
When carrying out medicines reconciliation, record relevant information on an electronic or paper-based form.
In primary care, carry out medicines reconciliation for all people who have been discharged from hospital or another care setting. This should happen as soon as is practically possible, before a prescription or new supply of medicines is issued and within 1 week of the GP practice receiving the information.
State the three C’s of medicine reconciliation
collecting information on medication history (prior to admission) using the most recent and accurate sources of information to create a full and current list of medicines, and
checking or verifying this list against the current prescription chart in the hospital, ensuring any discrepancies are accounted for and actioned appropriately, and
communicating through appropriate documentation, any changes, omissions and discrepancies.
List the sources of medication history
Patient / carer Recent print out from GP computer system Repeat prescription B side Hospital discharge summary Medication Administration Record (MAR) from nursing home Patient Medication Record (PMR) Clinical management plan Summary Care Record (SCR) ‘Message in a bottle’ Green bags Patient Own Drugs (PODs) Monitored Dosage System (MDS)
What can community pharmacists do for patients?
Recommended medicines-related information from GPs
1.Allergies or adverse reactions to medicines
Causative medicine
Brief description of reaction
Probability of occurrence
2.Medications prescribed for the patient
Current repeat and recent acute prescriptions
Medicine name – generic and brand (where
relevant)
Reason for medication (where known)
Form / strength
Dose and frequency / time
Route
3. Relevant previous medications
Recent medication changes – medications started,
stopped or dosage changed and reason for change
Key skills for medicines reconciliation
Effective communication skills
Essential for accurate transfer of information about medicines
Patient consultation skills
Technical knowledge of relevant medicines management processes
1. Medicines documentation (template)
PODs
GP systems
MDS
2. Therapeutic knowledge of medicines use
Knowledge of commonly used medicines
Basic understanding of pharmacology
Prescription interpretation
3. Legal requirements for prescribing, recording,
administration and storage of medicines.
Pharmacist role in MR
Pre-admission unit pharmacist
Acute admission unit pharmacist
Frail elderly services pharmacist
Emergency department pharmacist
Hospital Pharmacy Services
Reduce missed doses
Reduce prescription errors
Improve medicines reconciliation
Support senior clinical decision making
Optimise flow through hospitals across the week
Improve patient safety and clinical productivity
Decrease waiting times for discharge through the timely supply of medicines
Role of pre-admission clinic pharmacist
Medication history taking / medicines reconciliation
Checking PODs.
Advice to medical staff on administration of medicines during peri-operative period.
Prescribing +/- IP
Writing inpatient prescription
Writing discharge prescription
Supply of medicines for inpatient use and discharge.
One-stop dispensing
Counselling patients on current medicines and post-operative therapy.
Health promotion.
Role of AAU pharmacist
Medication history taking / Medicines reconciliation.
Assessment of PODS and supply of medication for inpatient use and discharge
One-stop dispensing / reuse of PODs
Pro-active clinical role.
Medication error reduction.
Advice on consultant-led ward rounds.
Prescribing role +/- IP
Writing inpatient prescription
Writing discharge prescription
Counselling patients on current, new and discharge medicines.
Role of frail elderly services pharmacist
Frail older people > 75 years with co-morbidities
Reduced quality of life
Risk of admission and readmission
Loss of independence
Similar to AAU pharmacist role
Polypharmacy and de-prescribing
Prevent avoidable admission and readmission
Reduce length of stay
Role of Emergency Department (ED) Pharmacist
Medicines focused duties:
Medicines reconciliation on admission
Focus on high risk patient groups e.g. frail elderly
Optimising use of medicines on admission to ED and acute care
Medicines advice
Prescribing regular and urgently required medicines
Supporting medicine reconciliation pre-discharge +/- primary care liaison
Fast tracking of dispensing
Patient education
Independent prescriber
Patient assessment skills
West Midlands ED project
The potential of pharmacists to manage patients within ED.
4 groups of ED patient presentations:
Suitable for community pharmacy
Suitable for IP pharmacist
Suitable for IP pharmacist with additional advanced clinical training
Not suitable for pharmacist management – medical team only
IP pharmacists could manage 48.2% of ED attendees in Minors, under overall supervision of doctor.
