WHO The Third Global Patient Safety Challenge

Medication Without Harm

1

)

“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”

5

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

8

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.  

.    

>  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.

8

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