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The International Journal of Pharmacy Practice 2007; Supplement 2 B73 Practice and development audit An audit of drug allergy documentation in a district general hospital AK Husband 1 , C Lloyd 1 , AJ Worsley 1 and DM Skelly 2 1 University of Sunderland, Pasteur Building, Wharnecliffe Street, Sunderland SR1 3SD, UK and 2 Queen Elizabeth Hospital, Sherriff Hill, Gateshead NE9 6SX, UK. E-mail: [email protected] Drug allergies are currently an important issue in risk management within the NHS. Are they being documented correctly? Allergy status records and red alert wrist band use across three hospital directorates were checked and compared to the standard set in the trust drug policy Recording of allergy status is not in line with local policy and is often absent from patient records; this includes a clear statement for those patients with no drug allergies. Prominent allergy alert systems such as red wrist bands are not being used in line with local policy Drug allergies are a significant cause of avoidable adverse drug reactions amongst hospital in-patients and continue to result in fatal events. 1 Management of drug allergies can be achieved through maintenance of accurate and accessible information with reference to patients’ allergy status. Such records are paramount for good patient care and for effective risk man- agement within the NHS. 2 Hospitals should have a drug pol- icy in place detailing exactly how to process a patient with a drug allergy. Allergy status should be recorded within clinical notes according to agreed case-note architecture and, where applicable, on the drug chart or electronic prescribing system. The aim of this project was to audit the current standard of drug allergy recording on the inpatient wards of a district gen- eral hospital and the level of adherence to the trust drug policy. 3 Six inpatient wards; two from surgery, two from medicine and two from care of the elderly were visited over a 3-month period to examine drug allergy notation. Patients were ran- domly selected from each ward. For each patient the clinical notes and specific section for allergy on the drug kardex was checked for any reference to a drug allergy or for confirma- tion that no allergy exists. Patients with documented drug allergy were checked to see if a red alert wrist band had been issued. Information present in clinical notes or admission documentation was cross-referenced with the drug chart to ensure both documents contained the same information. Patients with no known drug allergies should have this con- firmed on their documentation; this was also recorded as being absent or present. Of 369 patients reviewed across three directorates, 99 (26.8%) had a history of a drug allergy confirmed using previous notes, discussion with the patient and information from the general practitioner. Ninety-five (25.7%) had a definitive record of drug allergy in the clinical notes or the drug chart. Of these patients, 42 (44.2%) had been issued a red alert wristband. Allergy recording was subject to variation between directorates: for care of the elderly wards 6 (1.6%) patients had a definite record of allergy, for medicine 17 (4.6%) had a definite record and for surgery 72 (19.5%); 274 (74.3%) had no drug allergy status recorded in the clinical notes or drug chart. This study shows that recording of drug allergy status among hospital inpatients is subject to variation within the same trust. The notation of drug allergy varied substantially across the three directorates, with the surgical directorate demon- strating a much higher rate of allergy notation than either medicine or care of the elderly. The contribution of pre- admission review for elective surgical procedures to this higher rate of documentation is not clear, but must be a con- sideration. Absent, illegible or incomplete documentation can lead to errors in treatment and diagnosis. 4 The study clearly shows that most patients (74.3%) do not have any drug allergy status recorded in either the clinical notes or drug chart. The study shows that records for patients who do have a definite history of drug allergy are poor, and that these patients were not routinely issued a red alert wrist band. Forty-two (44.2%) of the patients with a definite allergy were issued an alert wrist band. 1 BBC News. Coroner critical of allergy check. http://news. bbc.co.uk/1/hi/england/bradford/4842422.stm (accessed June 14, 2007). 2 Renvoize E, Grange A, Pinder J et al. Patient documenta- tion. On the records. Health Serv J1997;107:30–1. 3 Gateshead Health NHS Trust Policy DP23. Trust drug policy October 2006. 4 A spoonful of sugar: medicines management in NHS hos- pitals. London: Audit Commission; 2001. Focal points Introduction Method Results Discussion References

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The International Journal of Pharmacy Practice 2007; Supplement 2

B73

Practice and development audit

An audit of drug allergy documentation in a district general hospital

AK Husband1, C Lloyd1, AJ Worsley1 and DM Skelly2

1University of Sunderland, Pasteur Building, Wharnecliffe Street, Sunderland SR1 3SD, UK and 2Queen Elizabeth Hospital, Sherriff Hill, Gateshead NE9 6SX, UK. E-mail: [email protected]

■ Drug allergies are currently an important issue inrisk management within the NHS. Are they beingdocumented correctly?

■ Allergy status records and red alert wrist band useacross three hospital directorates were checkedand compared to the standard set in the trustdrug policy

■ Recording of allergy status is not in line with localpolicy and is often absent from patient records;this includes a clear statement for those patientswith no drug allergies.

■ Prominent allergy alert systems such as red wristbands are not being used in line with local policy

Drug allergies are a significant cause of avoidable adverse drugreactions amongst hospital in-patients and continue to resultin fatal events.1 Management of drug allergies can be achievedthrough maintenance of accurate and accessible informationwith reference to patients’ allergy status. Such records areparamount for good patient care and for effective risk man-agement within the NHS.2 Hospitals should have a drug pol-icy in place detailing exactly how to process a patient with adrug allergy. Allergy status should be recorded within clinicalnotes according to agreed case-note architecture and, whereapplicable, on the drug chart or electronic prescribing system.

The aim of this project was to audit the current standard ofdrug allergy recording on the inpatient wards of a district gen-eral hospital and the level of adherence to the trust drug policy.3

Six inpatient wards; two from surgery, two from medicineand two from care of the elderly were visited over a 3-monthperiod to examine drug allergy notation. Patients were ran-domly selected from each ward. For each patient the clinicalnotes and specific section for allergy on the drug kardex waschecked for any reference to a drug allergy or for confirma-

tion that no allergy exists. Patients with documented drugallergy were checked to see if a red alert wrist band had beenissued. Information present in clinical notes or admissiondocumentation was cross-referenced with the drug chart toensure both documents contained the same information.Patients with no known drug allergies should have this con-firmed on their documentation; this was also recorded asbeing absent or present.

Of 369 patients reviewed across three directorates, 99 (26.8%)had a history of a drug allergy confirmed using previousnotes, discussion with the patient and information from thegeneral practitioner. Ninety-five (25.7%) had a definitiverecord of drug allergy in the clinical notes or the drug chart.Of these patients, 42 (44.2%) had been issued a red alertwristband. Allergy recording was subject to variationbetween directorates: for care of the elderly wards 6 (1.6%)patients had a definite record of allergy, for medicine 17(4.6%) had a definite record and for surgery 72 (19.5%);274 (74.3%) had no drug allergy status recorded in the clinicalnotes or drug chart.

This study shows that recording of drug allergy status amonghospital inpatients is subject to variation within the sametrust. The notation of drug allergy varied substantially acrossthe three directorates, with the surgical directorate demon-strating a much higher rate of allergy notation than eithermedicine or care of the elderly. The contribution of pre-admission review for elective surgical procedures to thishigher rate of documentation is not clear, but must be a con-sideration. Absent, illegible or incomplete documentation canlead to errors in treatment and diagnosis.4 The study clearlyshows that most patients (74.3%) do not have any drugallergy status recorded in either the clinical notes or drugchart. The study shows that records for patients who do havea definite history of drug allergy are poor, and that thesepatients were not routinely issued a red alert wrist band.Forty-two (44.2%) of the patients with a definite allergy wereissued an alert wrist band.

1 BBC News. Coroner critical of allergy check. http://news.bbc.co.uk/1/hi/england/bradford/4842422.stm (accessedJune 14, 2007).

2 Renvoize E, Grange A, Pinder J et al. Patient documenta-tion. On the records. Health Serv J1997;107:30–1.

3 Gateshead Health NHS Trust Policy DP23. Trust drugpolicy October 2006.

4 A spoonful of sugar: medicines management in NHS hos-pitals. London: Audit Commission; 2001.

Focal points

Introduction

Method

Results

Discussion

References

The International Journal of Pharmacy Practice 2007; Supplement 2

B74

Secondary prevention of osteoporosis and compliance with bone-protection treatments

R Purohit2, A Worlsey2,1, W Baqir1,2 and D Campbell1,2

1Northumbria Healthcare NHS Foundation Trust, Pharmacy, North Tyneside Hospital, Rake Lane, North Shields NE29 8NH, UK and 2Sunderland University, Health and Natural Sciences School Office, Fleming Building, The Science Complex, Wharncliffe Street, Sunderland SR1 3SD, UK. E-mail: [email protected]

■ Half the patients at risk of fragility fractures arenot receiving bone-protection treatments

■ In younger patients (≤75 years), DEXA scanning isnot being done

■ Compliance with bone-protection treatments(especially bisphosphonates) is poor

The area served by Northumbria Healthcare, NorthumberlandCare Trust and North Tyneside Primary Care Trust has par-ticular problems with respect to osteoporosis. The hip frac-ture admission rate in Northumberland is one of the highest inthe United Kingdom, and North Tyneside has a high mortal-ity rate after falls (personal reference, Dr Mike Lavender,Public Health, Northumberland Care Trust). National Insti-tute for Health and Clinical Excellence (NICE) technologyappraisal 87 sets out clear criteria for the management offemales who either have had a previous fragility fracture orare diagnosed with osteoporosis.1 These criteria state that allat-risk women aged 75 years and over who have osteoporosisor previous fragility fracture should receive treatment withcalcium/vitamin D3 and bisphosphonate or a second-lineagent.1 Women at risk aged 74 years or below should havetreatment based on the results of a DEXA scan.

The aim of this study was to assess compliance with NICEcriteria and bone-protection treatments in a general practicepopulation.

NICE audit criteria can be found in the technology appraisal.1

The medical system of a 12 500-patient practice in North

Tyneside was searched for patients with documented fragilityfractures and osteoporosis. Records of these at-risk patientswere reviewed by the researcher to identify the number offractures, whether DEXA scanning was undertaken and whatbone-protection treatments were being used. Poor or no com-pliance with bone-protection treatment was defined as havingnot ordered at least one prescription or not ordering any pre-scriptions, in the last 6 months, respectively.

There were 128 patients at risk of future fractures (aged 75 yearsand over; n = 79, aged 65–74 years; n = 23, aged 64 years andunder; n = 26). Of these, 113 (88.3%) had a documenteddiagnosis of osteoporosis. In the <75 years groups, 24.5%had a DEXA scan (DEXA scanning not recommended in the≥75 years group). Forty-eight patients (37.5%) had a fragilityfracture, with the majority (n = 36) being ≥75 years. Only67 patients (52%) received treatment with a bisphosphonateand calcium/vitamin D3, and four patients received strontiumand calcium/vitamin D3. Fourteen patients were on bisphos-phonates alone. Poor or no compliance rates for bisphospho-nates were 28.4% and 17.3% respectively.

Only half of the patients at risk of future fractures werereceiving the recommended bone protection (calcium/vitaminD3 and bisphosphonate or strontium). The majority ofthese patients were on bisphosphonates. However, justunder half of these patients were either not requesting theirmedication or requesting medication intermittently. Thisproject did not seek to identify reasons for poor or non-compliance. Further work is needed to ensure that all at-risk patients are started on appropriate bone-protectiontreatment and the reasons for patients not requesting pre-scriptions identified.

1 National Institute for Health and Clinical Excellence(NICE). Bisphosphonates (alendronate, etidronate,risedronate), selective oestrogen receptor modulators(raloxifene) and parathyroid hormone (teriparatide) forthe secondary prevention of osteoporotic fragility frac-tures in postmenopausal women. Technology Appraisal87. London: NICE; 2005. www.nice.org.uk (accessedJune 14, 2007).

Focal points

Introduction

Method

Results

Discussion

Reference

The International Journal of Pharmacy Practice 2007; Supplement 2

B75

An audit of unlicensed and off-label prescribing in children from birth to twelve years in a North West England primary care trust

LE Bracken1, JA Forshaw1, IJ Cubbin1 and A McAlavey2

1Liverpool John Moores University, James Parsons Building, Byrom Street, Liverpool L3 3AF, UK and 2Great Sutton Medical Centre, Old Chester Road, Great Sutton, Ellesmere Port, CH66 3PB, UK. E-mail: [email protected]

■ Use of unlicensed or off-label medicines in paedi-atrics is a recognised risk to both patients andprescribers

■ In children under 6 years the prescribing incidencewas 3% and in those aged 6–12 years it was 1%

■ Respiratory (48%) and gastrointestinal (16%)drugs were the most commonly prescribed in theunder-6-year-, and skin (15%) and cardiovascular(13%) in the 6–12-year age groups

■ Shared care protocols carry an increased risk invol-ving communication between prescribers, but givethe benefit of regular consultations and combinedclinical experience in difficult cases

Unlicensed drugs are not licensed for any indication or age;off-label drugs are either not licensed for use in children orare used outside the terms of their product licence.1 In generalpractice, 10% of medicines prescribed for children werefound to be unlicensed or off-label.2 This figure rises to 36%in paediatric medical or surgical wards and is as high as 90%in neonatal intensive care.3 This investigation attempted toestablish the extent of unlicensed or off-label prescribing forthe age group of 0–12 years, separated into 0–6 and 6–12years, in a primary care trust (PCT) in the north west ofEngland.

A total population of 87 172 across all 13 practices within thePCT recorded 11 780 patients aged under 12 years. The pre-scription records for these patients were interrogated via thePACT data and the EMIS records evaluated with the patient’sage or date of birth being the starting point for the investiga-tion. The unlicensed and off-label medicines were categorisedaccording to British National Formulary for Children (BNFC)chapter listing.4

The use of unlicensed or off-label medicines accounts for 3%in the population of 0–6 year olds and 1% in those aged 6–12years. General practitioner (GP) initiation accounted for 70%(66) in those under 6 years while the rest were consultant led;in 6–12 year olds the ratio reduces to 50% (24). Respiratoryand gastrointestinal drugs were the most commonly pre-scribed, accounting for 48% (49) and 16% (16) respectivelyin the under 6s, while skin and cardiovascular drugs were pre-dominant in the 6–12 years group, accounting for 15% (7)and 13% (6) respectively. In all cases the main reason for adrug being off-label was age related: 77% (86) (under 6years) and 44% (21) (6–12 years) respectively. The studyfound that almost half of the unlicensed or off-label prescrip-tions in the under 6s were for respiratory drugs; salbutamolsyrup accounted for 31% (15) of those and beclometasone14% (7), fluticasone 14% (7) and salmeterol 29% (14) inhal-ers a total of 57% (28). Terbinafine cream used in the 6–12year olds accounted for 85% (6) of the skin prescribing, whileone-third of the cardiovascular prescribing was due to furo-semide (2) solution.

This study found that the incidence of unlicensed or off-labelmedicines prescribed was lower than the UK average of 10%in general practice.2 For some more serious conditions,shared care protocols exist. These seek to delineate the clini-cal responsibility between the GP and the consultant. If bothclinicians share the responsibility, there are obvious benefits,e.g. regular consultations and reviews, combined clinicalexperience, but clear communications, and sharing of find-ings are essential; and by the nature of the conditions beingtreated prescribing carries greater risks.

To ensure that children are not exposed to unnecessary risks,controlled clinical trials are required to determine the mostappropriate dose in children of different ages. The unfortunatetruth is that prescribers are forced to prescribe unlicensed oroff-label medicines, but with the addition of the BNFC to cur-rent paediatric reference texts,4 the risks can be better managed.

1 National Prescribing Centre. Prescribing for children.MeReC Bulletin 2000;11:5–8.

2 Medicines standard: national service framework for children,young people and maternity services. London: Depart-ment of Health; 2004.

3 McIntyre J, Conroy S, Avery A, Corns H and Choonara I.Unlicensed and off label prescribing of drugs in generalpractice. Arch Dis Child 2000; 83:498–501.

4 British Medical Association, Royal Pharmaceutical Soci-ety of Great Britain, Royal College of Paediatrics andChild Health. British national formulary for children.London: BMJ, RPSGB, RCPCH Publications; 2006.

Focal points

Introduction

Method

Results

Discussion

References

The International Journal of Pharmacy Practice 2007; Supplement 2

B76

Evaluating the quality of written medicines use reviews reports

KC Ruda and KMG Wood

School of Health and Life Sciences, Aston University, Birmingham B4 7ET, UK. E-mail: [email protected]

■ There are no published data on the completenessand quality of medicines use review (MUR) forms

■ There is a wide variation in the completeness andlegibility of MUR forms. This limits the usefulnessof the form to patients

■ MURs are being focused on prescription-only med-icines (POM) in patients over 50 years

■ It is difficult to judge whether MURs are goodvalue for money and are benefiting patients

The new pharmacy contract launched in April 2005 intro-duced three levels of service: essential, advanced andenhanced.1 Medicines use review (MUR) and prescriptionintervention are provided under advanced services onceaccreditation requirements have been met. A recent review bythe Department of Health, which showed that pharmacy con-tractors were exceeding the number of claims for MURs,2

does not consider the completeness of forms or the quality ofinterventions being made as a result of MURs. A copy of theMUR form is given to patients. The aim of this study is todetermine the quality and completeness of pharmacist-com-pleted MUR forms which have been received in general prac-titioner (GP) practices within a Birmingham primary caretrust (PCT).

The sample was all MUR forms completed by a range ofpharmacists and submitted to 10 GP practices and retained bythose practices over a 4-month period. The practices were thefirst 10, who had a practice pharmacist (to ensure MUR formswere kept), who agreed to participate in the study. The con-tent analysis covered: completeness, number and type ofdrugs recorded, age of patients, and the number and type ofinterventions. Results were coded and analysed using Micro-soft Excel. NHS ethics and PCT R&D approval was notsought as this was a service review.

Four-hundred and fifty MUR forms were analysed. Only 54(12%) of the forms were fully completed. Three-hundred andseventy-two (82.6%) of MURs were conducted with patientsover the age of 50 years. What the patient would like to getout of the review was not recorded for 159 patients (35%).Eighty-two (18.2%) forms were very difficult to read, with162 (36%) containing abbreviations that would not be under-stood by a patient. The majority of the recorded drugs wereprescription-only medicines (POMs), with only 10 (2.2%)showing a record of over-the-counter (OTC)/pharmacy (P) orcomplementary medicines. However, the checklist ofpatients’ compliance, appropriateness of formulation, effec-tiveness and side-effects of their medication was recorded on387 (86%) forms. The number of drugs being taken bypatients ranged from 1 to 16, with a mode of 4 and a medianof 5. Forty-four per cent (1042) of the total drugs recordedwere for cardiovascular conditions, the next highest categorybeing CNS drugs at 12.7% (301). A correlation graph (inExcel) showed no relationship between the number of drugsand the number of interventions. The top three interventionswere health-promotion advice, monitoring advice and doserationalisation. One-hundred and eighty-seven (35%) recom-mendations were referred to the GP for action.

The completeness of MUR forms was variable, but there wasa clear focus on POM medicines. The top recorded categoriesof drugs are not surprising given the age range of patients.One issue is the recording of non-POM medicines, which areprobably being taken by more patients than is being recorded,but it is not possible to ascertain whether this is due to incom-plete medication histories being taken or patients’ reluctanceto volunteer such information. MUR forms are given topatients, so it is disappointing that many are difficult to readand understand. Clearly MURs are being conducted in patientsaged over 50 years, but it does not appear from this study thatthe number of drugs being taken is an important factor in thenumber of interventions being made by pharmacists.

1 The new contract for community pharmacy. London:Pharmaceutical Services Negotiating Committee; 2004

2 Medicine use review – contractors exceeding annuallimits on numbers. London: Department of Health; 2006.

Focal points

Introduction

Method

Results

Discussion

References

The International Journal of Pharmacy Practice 2007; Supplement 2

B77

An investigation into the risk and benefits of adherence to the management of infection control guidelines issued by the local primary care trust

RL Aspinall1, IJ Cubbin1 and A McAlavey2

1Liverpool John Moores University, School of Pharmacy and Chemistry, James Parsons Building, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, UK and 2Western Cheshire Primary Care Trust, Great Sutton Medical Centre, Old Chester Road, Great Sutton, Ellesmere Port CH66 3PB, UK. E-mail: [email protected]

■ This investigation looked into general practitioner(GP) prescribing adherence to local guidelines forinfection control – looking specifically at co-amoxiclav, clarithromycin and all drugs belongingto the 4-quinolone class of antibacterials (BritishNational Formulary Chapter 5.1.12)

■ It was found that prescribing of these drugsaccounted for 15% of all antibacterials prescribed

■ Prescribing was often outwith the conditions andguidance in the formulary, and treatment choicesin these circumstances came down to prescriberpreference and experience

■ It is evident that processes to support GPs in orderto improve patient benefits and reduce variabilityof treatment are implemented and continued

Eighty per cent of antibiotic prescribing occurs in primarycare; approximately half of these antibiotics are used totreat respiratory tract infections, a large proportion of whichare viral. Doctors find antibiotic therapy difficult due topatient expectation and pressure to prescribe antibioticsthey believe to be clinically unjustifiable. They also worryabout failure to treat the few cases that lead to serious com-plications.1 All of these factors contribute to antibiotic res-istance and the risk of reduced efficacy of antibiotics in thefuture.

More prudent prescribing will fulfil a spectrum of pur-poses, including maximising effectiveness, minimising risksand costs, reducing the risk of resistance to antibiotics as wellas respecting patient choice.2 This report examines prescrib-ing patterns for a number of specialised and expensive antibi-otics with limited indications and suggests supportive measuresto improve general practitioner (GP) prescribing.

The investigation considered the antibacterials co-amoxiclav,clarithromycin and all drugs belonging to the 4-quinoloneclass of antibacterials prescribed within 13 GP practices in aprimary care trust (PCT) in the north west of England inDecember 2006 – a month recognised as providing high pre-scribing rates. Information regarding the indication for useand length of the course were retrieved from patient recordson EMIS, which repeats the method used for the December2005 data collection, to which the results were thencompared.

The practices served a population of 87644 patients, and4429 prescriptions were issued for an antibacterial drug inDecember 2006, compared to 4676 prescriptions in 2005. Theproportion of the population prescribed an antibacterial drugvaried between 3.5% and 6.4% (4.6% to 8.6% in 20053) foreach surgery. Of the 4429 antibacterial drugs prescribed, 414were for co-amoxiclav, 142 for clarithromycin and 130 werefor any one of the 4-quinolone drugs. These figures were 10%lower than for 2005.3

The local guidelines for infection control indicated thesedrugs as first line in very few conditions. However, prescrib-ing of these drugs accounted for 15% of all antibacterials pre-scribed. Frequently the prescribing of these drugs was forindications outwith the guidelines. Selection of drugs wasthen based on prescriber experience and preference ratherthan evidence. The risks associated with this behaviour arethat the drug may be unnecessary or inappropriate, increasingthe potential of resistance, and increasing costs to the PCT.Conversely it is argued that clinical experience by GPs ofindividual patients has the benefit of early intervention, rapidremoval of any bacterial infection and prevention of thepatient requiring further antibacterial drugs and enduring alonger episode of ill-health.

Further to the report submitted to the PCT after the datacollection of December 2005, some education to support anti-bacterial prescribing has been given, local microbiologydemographics and susceptibility reports have been circulated,and this second study conducted. The PCT is further support-ing GPs by introducing Scriptswitch, a software package thatsits above prescribing systems to highlight potentially betterchoices of drug therapy to all surgeries, and will provide indi-vidually tailored support to targeted practices.

Focal points

Introduction

Method

Results

Discussion

The International Journal of Pharmacy Practice 2007; Supplement 2

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1 National Prescribing Centre. Antibiotic prescribing: achallenge for primary care. MeReC Bulletin 2000;11:17–20.

2 Barber N. What constitutes good prescribing? BMJ1995;310:923–35.

3 Wheeldon R. An investigation into GP compliance withthe management of infection guidelines for a primary caretrust. Liverpool: Liverpool John Moores University; 2005.

Prison staff views about the management of methadone

CEL Richards1,2 and DH James2

1HMP Swansea, 200, Oystermouth Road, Swansea SA1 3SR, UK and 2Welsh School of Pharmacy, Cardiff University, Redwood Building, King Edward VII Avenue, Cardiff CF10 3XF, Wales, UK. E-mail: [email protected]

■ An investigation of the barriers associated withmethadone management using a qualitative ana-lysis of prison staff self-completed questionnaires

■ Findings highlighted antipathy to methadone,poor resources and lack of communication andtraining; however more training was requested

■ More training and communication must be a pri-ority coupled with better information technology

■ Prescribing levels should match those in the com-munity and the need for intensive aftercare for alldetoxified prisoners on release due to the dangersof the loss of tolerance

Methadone is internationally recommended for its use in opioidaddiction in the prison service.1 However, there are many prob-lems associated with its use due to limited resources,2 and poorunderstanding of the rationale for methadone management.3 Ithas been suggested that a lack of trained personnel may be animportant factor. Little is known about prison staff knowledgeand attitudes towards the methadone programme.

The aim of this study was to assess the views of prisonstaff about the management and administration of the metha-done programme, identifying barriers and facilitators.

The setting was a government-run Category B prison in SouthWales, with 425 remand and convicted adult male prisoners. Asemi-structured questionnaire was designed to assess the prob-lems with and barriers to methadone administration; prisonstaff attitudes, knowledge, training; and their opinions as tohow the service could be improved. A combination of open andclosed questions was included in the questionnaire, for self-completion by prison staff. Thematic analysis of the responsesto open-ended questions (i.e. qualitative data) was undertaken.

Thirty members of prison staff were recruited from a cross-section of the prison including management, prison officersand healthcare staff. The response rate to the questionnairewas 90%, with 27 questionnaires being returned. Seven themeswere identified representing the staff views about the man-agement programme. These were:

1 reluctance to give prisoners methadone 2 content of the methadone programme 3 barriers to good methadone management 4 efficiency of methadone management 5 availability of methadone 6 use of resources 7 staffing roles.

Of the staff that were reluctant to give methadone, noneseemed to understand the rationale of the harm reduction inmethadone management. Poor communication was identifiedboth internally within the prison and externally betweenprisons. Prison staff agreed that prescribing levels shouldmatch those in the community with better aftercare onrelease. They also requested more training.

More training and education for staff regarding the rationale ofthe methadone management was a priority highlighted in thisstudy. Better communication both internally and externally wasalso another recommendation; improved information techno-logy is needed and the development of an inter-prison forum toimprove communication. Positive findings were that staffrequested prescribing levels should match those in the com-munity according to the Models of Care Guidance,4 and theysaw the need for close and intensive aftercare for all detoxifiedprisoners on release due to the dangers of the loss of tolerance.

References

Focal points

Introduction

Method

Results

Discussion

The International Journal of Pharmacy Practice 2007; Supplement 2

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1 United Nations Office on Drugs and Crime. Substitutionmaintenance therapy in the management of opioiddependence and HIV/AIDS prevention. Geneva: WorldHealth Organization; 2004.

2 Keavney PJ. Prison medicine: a crisis waiting to break.London: British Medical Association; 2004.

3 Caplehorn J, Gerlach R. Attitudes and beliefs of doctorsprescribing methadone to addicts in the Westfalen-Lipperegion of Germany. Drug Alcohol Rev 1999;18:163–70.

4 Department of Health, National Treatment Agency Initia-tive. Models of care guidance. London: The StationeryOffice; 2001.

An audit of the appropriateness of prescribing in elderly patients with a history of falls

A Patel1, N Patel1, A Oborne2 and A Buttery2

1King’s College London, Pharmacy Department, Franklin-Wilkins Buidling, 150 Stamford Street, London SE1 9NH, UK and 2Guys & St. Thomas’ Foundation NHS Trust, Lambeth Palace Road, London SE1 7EH, UK. E-mail: [email protected]

■ Is prescribing of drugs appropriate in elderly inpa-tients who have fallen?

■ Elderly patients receive multiple drugs, includingdrugs associated with falls

■ Some aspects of the management of falls areappropriate, but others require better prescribing

An estimated four out of five people over 75 years take atleast one prescribed drug.1 Falls are one of the most commonproblems in elderly patients and are associated with fracturesand reduced mobility, leading to loss of confidence, reducedindependence and hospital admission.2 Polypharmacy in eld-erly patients may increase falls, but vitamin D reduces falls.2

This audit investigated prescribing in elderly inpatients whofall, including the appropriateness of prescribing vitamin D,calcium and bisphosphonates.

The work was conducted in a large teaching hospital.Inpatients were identified by physiotherapists who conducted

a ‘falls and at risk of falls’ assessment during routine care,according to preset criteria. The data collector used a data-collection form to record patients’ falls history, falls risk fac-tors (reduced gait/mobility, polypharmacy, a cardiovascularcondition, visual or cognitive impairment, muscle weaknessand home hazards). All current drugs were recorded, includingbone protection (calcium/vitamin D, bisphosphonates), corti-costeroids and drugs associated with falls (including antihy-pertensives, diuretics, and psychotropics). Contraindicationsto bone-protection drugs were recorded.

Data were collected for 126 inpatients. Of these, 87 (69%) fell:32 (25%) presented having fallen and 55 (44%) had a history offalls. These patients sustained a median of two falls in the previ-ous 12 months. Physiotherapists rated 11 (9%) patients as at riskof falling. The mean number of drugs prescribed was similar forpatients who fell versus those patients at risk or with no falls (7.8versus 7.6 items per patient). Most patients (76/87, 87%) present-ing with a history of falls who fell received one or more drugsassociated with falls (a total 202 drugs, mean 2.4 per patient,maximum three items per patient). These included risperidone (1,1%), temazepam (1, 1% patients), chlordiazepoxide (1, 1%), tri-cyclic antidepressants (5, 6%), non-tricyclic antidepressants (13,15%) and digoxin (12, 14%). Thirty-nine patients (45%) alsoreceived laxatives, diuretics (25, 29%), and antihypertensives(51, 59%). One-third (31/87) of patients who fell were prescribedvitamin D, usually with calcium. Only 11/21 (53%) patients withprevious fractures received bone-protection drug(s). Contraindi-cations were rarely documented when bone protection was omit-ted. Of 48 patients with four or more falls risk factors, 50% wereprescribed two or more drugs associated with falls; only 17% ofthese patients were prescribed a bone-protection drug(s).

Physiotherapist referrals to pharmacists can be used to identifypatients who fall and who may benefit from medicationreview. Patients who fall or are at risk of falls received multi-ple drugs, some of which are associated with falls. Prescribingof many of these drugs is a risk versus benefit decision wherethe clinical benefit must be weighed against any increase inthe risk of falling. Unfortunately, vitamin D is underused inpatients who fall. Bone protection is also underused in patientswith previous fractures, but, more reassuringly, the generaluse of hypnotics and other psychotropics was low.

1 National service framework for older people. London:Department of Health; 2001. www.dh.gov.uk/assetRoot/04/07/12/83/04071283.pdf (accessed June 14, 2007).

2 Tinetti ME. Guideline for the prevention of falls in olderpersons. J Am Geriat Soc 2001;49:664–72.

References

Focal points

Introduction

Method

Results

Discussion

References

The International Journal of Pharmacy Practice 2007; Supplement 2

B80

A critique of the medicines use review paperwork: is it fit for purpose?

R Thomas, D Higman James and D John

Cardiff University, Redwood Building, King Edward VII Avenue, Cardiff CF10 3XF, Wales, UK. E-mail: [email protected]

■ The objective of this study was to gauge opinionsfrom general practitioners (GPs), community andprimary care organisation (PCO) pharmacists inWales as to the fitness for purpose of the medi-cines use review (MUR) paperwork

■ Thirty-three participants undertook a written cri-tique of the MUR form to indicate its strengths,weaknesses and their recommendations for change

■ Although the overall impression of the MURpaperwork was poor, many of the shortcomingsidentified have already been addressed in a recentredesign of the form. However, based on the find-ings of this study, further modifications may benecessary to enhance its fitness for purpose

Medicines use review (MUR) is an advanced-level servicewithin the pharmacy contractual framework, implemented inApril 2005. Anecdotal feedback suggests that there may be anumber of concerns about the usefulness and effectiveness ofthe MUR paperwork. The objective of this study was togauge opinions on the usefulness of the MUR paperwork(first version), in order to identify whether it is fit for purpose.

Community pharmacists (n = 13), local health board (LHB)pharmacists (n = 11), general practitioners (GPs) (n = 8), onepractice manager and a practice-based pharmacist took part ina research workshop in either Cardiff or Newtown in December2006. Participants were selected on the basis of nominationby LHBs’ heads of pharmacy/medicines management. Partic-ipants were provided with a template in order to systemati-cally evaluate what they liked and disliked about each sectionof the MUR form and what changes they would suggest.They were also asked to state whether the MUR paperwork

met their expectations (exceeded, met or did not meet). Thismethod has been validated in a previous study.1

The 33 participants represented 19 out of the 22 LHBs inWales. Most workshop attendees (n = 27) considered theMUR paperwork did not meet their expectations, with themost common reasons cited being that it is too time consumingand cumbersome to complete and not IT compatible. It was feltthat too much information is recorded, some of which isduplicated, and not all is relevant. Specific comments weremade for which parts of the form should be removed and oth-ers which could be improved. In general, GPs wanted a clearindication on the front of the form whether any action isrequired on their part. Some community pharmacists sug-gested an electronic version of the form with an ‘auto fill’function on the pharmacy computer system, which could thenbe electronically transferred to the GP surgery.

Since this study was conducted, a revised version of the MURpaperwork has been developed by the Pharmaceutical ServicesNegotiating Committee (PSNC) and Community PharmacyWales (CPW) and circulated for consultation. It is encourag-ing to note that many of the suggestions for change presentedin this study have already been addressed in the draft modifiedMUR form.2 Based on these findings, further modificationsmay be necessary to enhance its fitness for purpose. How-ever, although many of the presentational issues have beenremedied, finding IT solutions may pose more of a challenge.

The authors wish to thank the Welsh Assembly Governmentfor funding this research.

1 James DH, John DN, Hughes ML, Davies M, Roberts D. Asystematic evaluation of pharmacists’ views on the RoyalPharmaceutical Society of Great Britain’s (RPSGB) draftcontinuing professional development (CPD) feedbackreport: a novel study design. Cardiff: STS Publishing; 2006.

2 Anon. PSNC consults on draft of modified MUR form.Pharm J 2007;278:97.

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Method

Results

Discussion

Acknowledgements

References

The International Journal of Pharmacy Practice 2007; Supplement 2

B81

The choice, route and duration of antibiotic treatment for community-acquired pneumonia

CA Langley1, Y Akhtar1 and N Jacques2

1School of Life and Health Sciences, Aston University, Birmingham B4 7ET UK and 2Heart of England NHS Foundation Trust, Solihull Hospital, West Midlands B91 2JL, UK. E-mail: [email protected]

■ There is a perception that intravenous antibioticsmay be being overused in the treatment ofcommunity-acquired pneumonia (CAP)

■ It was found that patients diagnosed with CAP didnot all have their consolidation status recorded intheir medical records

■ A high proportion of patients diagnosed with CAPare not being treated with the appropriate routeand choice of antibiotics in accordance with thetrust guidelines

■ Improvements in compliance with trust guidelinesin the treatment of CAP will reduce length ofintravenous antibiotic use, hospital stay and cost

The severity of community-acquired pneumonia (CAP) isdetermined by the CURB-65 score given to patients uponadmission to hospital. A score of <3 indicates non-severe dis-ease that can be treated adequately with oral antibiotics. A scoreof ≥3 indicates severe disease and should be treated with a shortcourse of intravenous antibiotic therapy followed by an oralcourse of antibiotics.1 There is a perception that intravenousantibiotics may be being overused in the treatment of CAP. Theaim of this project was to ascertain whether prescribers werefollowing local trust guidelines for the treatment of CAP.

Data were collected using a data-collection tool specificallydesigned for the project. Patients that were treated for CAPwere identified on admission wards of Solihull Hospital andHeartlands Hospital for a total period of 8 weeks (January toFebruary 2006). Parameters collected included patient identi-fication number, consolidation status (consolidation is wherethe alveoli in the lung are filled with fluid produced byinflamed tissue such as in pneumonia; it presents as shadows

on a chest X-ray), CURB-65 score, pre-admission antibiotics,white cell count, temperature, microbiological sensitivitydata, drug details and length of course of antibiotics. The datawere analysed against the first-line antibiotic therapy for thetreatment of CAP (local trust guidelines) and defined criteriafor switch of intravenous to oral antibiotics.

The mean length of a course of intravenous antibiotics was2.5 days; the mean length of an oral course of antibiotics was8.2 days; and the mean length of hospital stay was 11.5 days.It was found that patients diagnosed with CAP did not allhave their consolidation status recorded in their medicalrecords. In total, 31 patients were identified as being treatedfor CAP over the 8-week period. Nine out of 31 (29.0%) had aCURB-65 score of ≥3, of which 16.2% (n = 5) were initiatedon first-line intravenous antibiotic therapy, benzylpenicillinand levofloxacin. None of these five patients was subse-quently correctly switched to oral amoxicillin and clarithro-mycin. The remaining 12.8% (n = 4) were initiated on oralregimens or non-recommended intravenous antibiotics. Nine-teen out of 31 patients (61.3%) in total scored <3, of which9.7% (n = 3) were started correctly on oral amoxicillin andclarithromycin, 51.6% (n = 16) were treated with treatmentregimens other than that stated in the trust policy. The remain-ing three patients (9.7%) were unnecessarily treated for CAP.Out of 14 patients treated with intravenous antibiotics fol-lowed by oral antibiotics, 50.0% (n = 7) switched to oral ontime (in accordance with treatment algorithm for CAP),21.4% (n = 3) switched late, and 28.6% (n = 4) switched early.

A high proportion of patients diagnosed with CAP are notbeing treated with the appropriate route and choice of antibi-otics in accordance with the trust guidelines for the treatmentof CAP. Therefore prescribers should improve compliancewith trust guidelines in the treatment of CAP. The introduc-tion of a treatment algorithm for the switch of intravenous tooral antibiotics can result in more appropriate switch timing.This would help to reduce the length of intravenous antibioticuse, hospital stay and cost. Feedback to prescribers on thefindings from this study is under way, and a further study tomonitor compliance will be undertaken.

1 Pass SE, Gearhart MM, Young EJ. Short-course antimi-crobial therapy for the treatment of pneumonia. J PharmPract 2005;18:18–24.

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References

The International Journal of Pharmacy Practice 2007; Supplement 2

B82

Audit of the accuracy and consistency of drug allergy recording

KO Oloyede1, J Davison2 and R Etherington1

1Sunderland Pharmacy School, University of Sunderland, Wharncliffe Street SR1 3SD, UK and 2Pharmacy Department, City Hospitals Sunderland, Sunderland SR4 7TP, UK. E-mail: [email protected]

■ Allergy status recording was audited across threesources of hospital patient medical record systems

■ The majority of allergies recorded on the electronicprescribing system were made by pharmacistsinstead of doctors

■ The allergic reaction was not recorded in nearly40% of cases

■ Pharmacists could play a role in raising awarenessof the importance of allergy status recording

Drug allergy is becoming an increasingly common problemin the hospital setting. Allergic reactions to drugs can havelife-threatening consequences and are estimated to prolongthe hospital stay for 15% of patients,1 therefore the recordingof allergy status is essential for patient safety. At City HospitalsSunderland, allergy status is recorded on three systems – themedical notes (by the doctor), the pharmacy patient profile(by the pharmacist) and the electronic prescribing system (bythe doctor, but this can be amended by the pharmacist). Oneof the benefits of an electronic prescribing system (EP) is thatit allows a comprehensive audit trail of the informationrecorded,2 and therefore, the person entering the allergy statusonto the system can be identified.

The objectives of the study were to:

• evaluate if all of the information sources were completewith allergy status and whether they were consistent

• determine who recorded the allergy status on the EP.

The audit was carried out over a 3-month period on the elderlycare admissions unit. The documented allergy status and the

reported allergic reaction were recorded from the patients’ med-ical notes and the pharmacy patient profile (PPP). The samedata were recorded from the EP with the addition of whether ithad been entered by a pharmacist or a doctor. Supportinginformation on adverse drug reaction (ADR) was collected, as itis not always clear if a reaction is due to an allergy or an ADR.

Records from a random sample of 100 patients were analysedduring the period of the study. Allergies to nine differentdrugs were documented, the majority being to penicillin(n = 7). Fifteen per cent of patients had ‘known drug allergy’(KDA) documented on the PPPs, 14% had KDA documentedin the medical notes and 13% had KDA documented in theEP. Therefore, 13% of patients had KDA recorded on allthree record systems. From the 100 EP records analysed, 78%of allergy status was recorded by the pharmacist, and 22% bythe doctor. In five cases of KDA, the allergic reaction was notrecorded, and on two occasions an allergy was recordedwhereas it was in fact an ADR.

Allergy status should be recorded by medical staff on the EPsystem, yet doctors are clearly omitting to record thisinformation as 78% of the entries were made by pharmacists.In nearly 40% of the patients with KDA, the allergic reactionwas not recorded and there were minor discrepancies in therecording of allergy status across the three systems used inthe hospitals. Records of drug allergies are recognised as keycomponents of patient records,3 and are necessary for avoid-ing inappropriate prescribing. The results of this study dem-onstrate a need for raising the awareness of the importance ofaccurate and complete allergy status recording, and the poten-tial for pharmacists to play a proactive role in this.

1 Allergy – the unmet need: a blueprint for better patientcare. London: Royal College of Physicians; 2003.

2 Goundrey-Smith S. Electronic prescribing experience inthe UK and system design issues. Pharm J 2006;277:485–9.

3 Horsfield P. Representation of drug allergies, intolerancesand adverse reactions in GP electronic patient records.Worcester: Primary Health Care Specialist Group; 2005.

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References

The International Journal of Pharmacy Practice 2007; Supplement 2

B83

A re-audit of cefuroxime and metronidazole prophylaxis in general surgery following the introduction of mandatory stop dates

P Patel1, J Holden2 and R Etherington1

1Sunderland Pharmacy School, University of Sunderland, Wharncliffe Street SR1 3SD, UK and 2Pharmacy Department, City Hospitals Sunderland, Sunderland SR4 7TP, UK. E-mail: [email protected]

■ Antibiotic prophylaxis in general surgery was re-audited following the implementation of manda-tory stop dates

■ 20% more patients received in excess of the pro-phylactic dose of cefuroxime and metronidazoleafter the introduction of mandatory stop dates

■ 8% of surgical patients received no antibioticprophylaxis

■ There is an increased need for pharmacists to chal-lenge inappropriate prescribing

Cefuroxime and metronidazole are widely used in combina-tion in general surgery for the purpose of reducing post-operative wound infections. Current prescribing guidelines(British National Formulary (BNF) and Scottish Intercollegi-ate Guidelines Network (SIGN)) recommend a maximum oftwo peri-operative and three post-operative antibiotic prophy-lactic doses. Adherence to prescribing guidelines is expectedto reduce the incidence of surgical site infections, the inap-propriate use of antibiotics. and costs to hospitals.1 A previousstudy of antibiotic prescribing at Sunderland Royal Hospitalhas shown that 55% of patients received more than the rec-ommended prophylactic dose of cefuroxime and metronida-zole.2 The absence of stop dates was identified as a possiblecontributor to the extended courses prescribed. The pharmacydepartment subsequently implemented mandatory stop datesfor antibiotics on the electronic prescribing system. Thisensured that the prescriber had to enter a stop date at the timea prescription was entered.

The objectives of the study were to:

• undertake a re-audit of cefuroxime and metronidazole pre-scribing in general surgery

• evaluate whether the implementation of mandatory stopdates reduced the number of prophylactic doses.

Data were collected over a 3-month period (November toJanuary) from patients admitted to vascular and gastrointestinalsurgery wards. All the patients who were prescribed cefurox-ime and metronidazole were identified from the Hospital Infor-mation System (HISS) and details of dose, frequency, start andstop dates were recorded. Medical notes were scrutinised forsurgical procedure and additional information which wouldindicate the need for a prolonged course of therapy.

Data were collected from 50 patients who were prescribedcefuroxime and metronidazole during the period of the study.Antibiotic prophylaxis is recommended for all of the surgicalprocedures (19 in total) included in the study. Seventy-fourper cent of patients (n = 37) received prolonged prophylactictreatment (more than five doses in the peri- and post-opera-tive period). The number of antibiotic doses administeredranged from zero to 34 doses. Eight per cent of patients(n = 4) did not receive any antibiotic prophylaxis.

Almost 75% of patients receiving cefuroxime and metronida-zole were prescribed in excess of the recommended prophy-lactic doses. This represents an overall increase of 20% whencompared to the previous study carried out prior to the intro-duction of the stop dates. The stop dates may actually serve toprolong antibiotic courses as there is no need for review ofpatients’ medication on an ongoing basis. This illustrates theneed for continued further education of medical staff, a rolefor pharmacists in challenging inappropriate prescribing, andagreed local guidelines.

In the patients who were prescribed no antibiotic prophy-laxis even when it was indicated, there is a considerable riskof surgical site infection. These patients are at increased riskof morbidity, extended hospital stay and associated healthcarecosts.3

1 Waddell TK, Rotstein OD. Antimicrobial prophylaxis insurgery. Committee on Antimcrobial Agents, CanadianInfectious Disease Society. Can Med Assoc J1994;151:925–31.

2 Mohammed F, Holden J, Etherington R. Audit of cefurox-ime and metronidazole prophylaxis in general surgery atSunderland Royal Hospital. Int J Pharm Pract2006;14:B115–16.

3 Song F, Glenny AM. Antimicrobial prophylaxis in colo-rectal surgery: a systematic review of randomised controlledtrials. Health Technol Assessment 1998;2(7).

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References

The International Journal of Pharmacy Practice 2007; Supplement 2

B84

An investigation into the compliance of general medical practitioners to NICE guidelines for the prescribing of the anti-obesity drugs orlistat and sibutramine

M Saremi, IJ Cubbin and J Hickey

School of Pharmacy and Chemistry, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, UK. E-mail: [email protected]

■ The compliance of general practitioners’ (GPs’) pre-scribing to NICE (National Institute for Health andClinical Excellence) guidelines for the anti-obesitydrugs orlistat and sibutramine was assessed in all 13GP practices of a primary care trust in north westEngland

■ Interrogation of patients’ computer records indi-cated that for orlistat 57% (n = 454), and for sibu-tramine 64% (n = 105) of GPs’ prescribing, over3 years, complied with the guidelines

■ The extent of compliance varied considerablybetween the practices and the guidance criteria points

■ These drugs should not be prescribed unless ade-quate arrangements for monitoring and adviceare in place

Obesity affects a large percentage of the population, is associ-ated with serious medical complications, and has considerableeconomic consequences.1 The prevalence of obesity is risingin England, and over 50% of all adults are now known to beeither overweight or obese.1 Current estimates for the costsof obesity in England vary between £6.6 and £7.4 billion.1

Orlistat and sibutramine produce average placebo-subtractedweight losses of less than 5%.2 However, combined with life-style modifications the clinically significant weight losses of5–10% are achievable.2 The National Institute for Health andClinical Excellence (NICE) technology appraisal guidelinesfor orlistat and sibutramine (2004) are now updated by NICEobesity guidelines (December 13, 2006).1

The aim of this study was to investigate the compliance ofGPs to NICE guidelines (2004) for the prescribing of the anti-obesity drugs orlistat and sibutramine.

A criteria-based clinical audit was utilised to record the propor-tion of treatments adhering to the NICE guidelines (2004).Searches were performed for all patients prescribed either orli-stat or sibutramine between January 1, 2004 and December 31,

2006, in all the GP practices of a primary care trust (PCT) innorth west England. The computer records and prescribing ana-lysis and cost tabulation (PACT) data of these patients wereexamined against each of the five criteria for orlistat, and sevencriteria for sibutramine, listed in the guidelines. The overallpercentage compliance for each drug was determined as themean of the percentage compliances of the individual criterion.

The compliance varied considerably between practices, aswell as between guidance criteria. None of the 13 practicesdemonstrated compliance above 90% for either drug. Acrossthe PCT, overall compliance (mean ± standard deviation) fororlistat was 57 ± 14.9%; n = 454, and for sibutramine64 ± 15.3%; n = 105. For orlistat, 200 (44%) patients discon-tinued treatment within the first 3 months. Using the key cri-terion of 5% weight loss at 3 months, 130 of the remaining254 (51%) failed to meet the criterion. For sibutramine, theloss was even greater: 69 patients (66%) in the first 3 monthsand 14 (39%) continued on treatment without the 5% weightloss. High initial attrition was due to patient intolerance andlack of motivation.

Orlistat and sibutramine should not be prescribed unless ade-quate arrangements for regular review and offering informa-tion support and counselling on additional diet, physicalactivity and behavioural strategies are in place. The reasonfor non-compliance to the NICE guidelines could arise fromthe possibility that there are no arrangements for the system-atic weight management services at practice or PCT levels.Another reason could be poor record keeping that preventsthe continuity of care. When prescribing for the first time,baseline weight and target weight at 3 months (5% reductionof the initial weight) should be recorded and made explicit tothe patient. For the first 3 months, it is recommended that thepatients could be reviewed every 2 weeks for monitoring,counselling and their 2-week prescription. A weekly target ofbetween 0.5 and 1 kg weight loss should also be set. Prescrip-tions should be issued on review, and not exceed a 1-monthsupply. If the 5% weight loss is achieved, the patient shouldthen be reviewed at least quarterly; orlistat can then be con-tinued in patients who maintain their weight loss, and sibu-tramine can be continued for a year with the exception ofpatients who regain 3 kg or more.

1 Clinical guideline 43: Obesity. London: National Institutefor Health and Clinical Excellence, National Collaborat-ing Centre for Primary Care; 2006.

2 Padwal RS, Majumdar SR. Drug treatments for obesity:orlistat, sibutramine, and rimonabant. Lancet2007;369:71–7.

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Discussion

References

The International Journal of Pharmacy Practice 2007; Supplement 2

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Correlation between the proportional use of insulin analogue therapy and the general medical services Quality and Outcomes Framework DM6 target in the north east of England in 2005–2006

W Horsley and G Masters

Regional Drug and Therapeutics Centre, Newcastle, Wolfson Unit, 24 Claremont Place, Newcastle NE2 4HH, UK. E-mail: [email protected]

■ Increased prescribing of insulin analogue therapyrelative to all insulin is associated with a lowerlevel of attainment of the Quality and Outcomesframework (QoF) DM6 target (proportion ofdiabetic patients with a haemoglobin(Hb)A1c < 7.4%)

■ A statistically significant negative correlation of29% (P < 0.0005) exists between the proportionaluse of insulin analogues and the DM6 target

■ These results may form the basis for initiating anaudit of insulin analogue therapy to determinewhether they are applicable in local situations

The use of insulin analogues has grown rapidly since the launchof the first insulin analogue in 1996, with their use accountingfor 60% of all insulin items in England in 2005–2006. They areclaimed to provide several advantages over human insulinincluding marginal decreases in haemoglobin (Hb)A1c levels.1,2

To test these claims in practice we compared the use of insulinanalogues, measured as the number of insulin analogue items asa proportion of the total number of all insulin items, and com-pared these levels to the proportion of patients with aHbA1c <7.4% as per the Quality and Outcomes Framework(QoF) DM6 target of the general medical services (GMS).

Data were extracted from the NHS Business Services Author-ity Prescription Pricing Division ePact database for all gen-eral practices with at least 15 diabetic patients in 10 out of 12primary care trusts (PCTs) within the North East StrategicHealth Authority. The period for which data were extractedwas the financial year April 2005 to March 2006 inclusive.Data extracted included the total number of insulin items pre-scribed and the total number of insulin analogue items pre-scribed. The DM6 QoF target data for each practice for thesame period were obtained from the Information Centre for

Health and Social Care website (www.ic.nhs.uk). A scatterplot, Pearson’s correlation and least squares regression wereproduced using ‘proportion of insulin analogues’ as the inde-pendent variable and the ‘proportion of diabetic patientsmeeting the DM6 target’ as the dependent variable.

A total of 309 practices was included in the analysis. Themean proportional use of insulin analogues was 49.3% (range6.7 to 100%). The mean proportion of patients with aHbA1c < 7.4% was 64.5% (range 0 to 100%). The scatter plotaxes cross at the mean values for each (49.3, 64.5). The plot-ted points demonstrate a clear but relatively dispersed patternwith a slight downward gradient running from left to right.Fourteen outliers were identified after fitting a least squaresregression line which runs through the axis intersection. Theline demonstrated a negative correlation of 29% (P < 0.0005).

An important point to note is that the DM6 target relates to alldiabetic patients, of which only an estimated 30% will beinsulin dependent.3,4 Therefore the data are confounded by alarge proportion of patients whose HbA1c is not affected byexogenous insulin therapy. Nonetheless, the correlation ishighly statistically significant. Greater use of insulin analoguesmay be the cause of the observed effect, or it may be due to agreater proportion of intervention-resistant diabetic patients,or there may be an as-yet undetermined explanatory factor.Additional confounding factors that are not accounted for inthe model include the extent of exception reporting in theQoF data, and measures of social and economic deprivation.These results suggest that increased use of analogue insulinrelative to all insulin therapy may not improve patient glycae-mic control; however, individual practice assessment is rec-ommended to determine whether this is true at a local level.We intend to further investigate whether this effect is linkedto short- or long-acting insulin analogue therapy or both.

1 Siebenhofer A, Plank J, Berghold A et al. Short actinginsulin analogues versus regular human insulin in patientswith diabetes mellitus (Cochrane Review). The CochraneLibrary Issue 2. Oxford: Update Software; 2006.

2 Peterson GE. Intermediate and long-acting insulins: areview of NPH insulin, insulin glargine and insulindetemir. Curr Med Res Opin 2006;22:2613–19.

3 Forouhi NG, Merrick D, Goyder E et al. Diabetes preva-lence in England 2001, estimates from an epidemiologicalmodel. Diabet Med 2006;23:189–97.

4 Newnham A, Ryan R, Khunti K et al. Prevalence of diag-nosed diabetes mellitus in general practice in England andWales, 1994 to 1998. Health Stat Q 2002;14:5–13.

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References

The International Journal of Pharmacy Practice 2007; Supplement 2

B86

A community pharmacy audit of patient compliance with medication for osteoporosis

M McGovern, H Millar, V Reilly and DAM Thomson

NHS Greater Glasgow & Clyde, Primary Care Division, Queens Park House, Victoria Infirmary Glasgow, Scotland, UK. E-mail: [email protected]

■ An audit of patient compliance with medicines forosteoporosis was conducted

■ Fifty-two pharmacies administered a structuredquestionnaire on osteoporosis medication to 353patient or carers

■ Not all patients were taking their medicines asprescribed; however, community pharmacists dem-onstrated that they could counsel the majority ofthese

■ Further training and support material should beoffered to community pharmacists to aid patientcounselling on medicines for osteoporosis

In Scotland 1 in 3 women and 1 in 12 men over the age of50 years are affected by osteoporosis, resulting in 20000cases of osteoporotic fractures annually.1 Selection of drugtherapy for osteoporosis treatment and prevention mayinclude bisphosphonates and calcium supplements.1 Somepatients do not continue with their medication due to a lack ofunderstanding of dosage regimens or side-effects.2 An auditwas undertaken to assess if patients presenting with prescrip-tions for bisphosphonates and/or calcium supplements weretaking these as intended by prescribers. Two standards wereset: 80% of osteoporosis patients should be taking osteoporo-sis treatment as prescribed, and 90% of osteoporosis patients/carers should receive counselling on these medicines in thepharmacy.

All community pharmacies in Glasgow were invited to parti-cipate in the audit. Pharmacists were asked to question andcomplete a structured questionnaire with patients or theircarers presenting with prescriptions for bisphosphonates andcalcium supplements over a 4-week period.

Data collected included demographic details and concomi-tant therapies. Questions explored patient compliance withtherapy, reasons for non-compliance, and knowledge of howto take bisphosphonates. The community pharmacist thenoffered verbal counselling to the patient or their carer to

address problems identified. Audit facilitators distributedproject material, collated results and disseminated these data.

Ethics approval was not required as this was an audit ofnormal community pharmacy activity.

Fifty-two (24%) pharmacies representing a range of communitysettings and social deprivation collected data from 353 patientsor carers.

Seventy per cent of the patients were prescribed a bisphos-phonate and a calcium supplement, with 17% on only abisphosphonate and 13% on calcium alone. Seventy-seven(22%) patients stated that they did not always take their med-ication. Reasons for non-compliance included: they forgot 41(46%); they disliked the taste 20 (22%); miscellaneous rea-sons 12 (13%); stomach upset 9 (10%); fed up taking 6 (7%);unsure of the indication 2 (2%) (more than one reason couldbe cited).

Of those patients taking bisphosphonates, over 88%understood that they should swallow the tablet whole, uponrising, with 200 ml of water, remaining upright for 30 min,avoiding food or other medication, and 70% stated that theyknew they couldn’t substitute mineral water or fruit juice forwater.

Of 210 patients co-prescribed calcium, iron or antacidpreparations with bisphosphonates, 32 (15%) did not realisethat they should avoid concomitant administration.

Community pharmacists offered further counselling onadministration of osteoporosis medication either directly orthrough carers, to 342 patients (97%).

The relatively modest participation in this audit by com-munity pharmacists may be explained by increased demandson pharmacist time, with the introduction of a new phar-macy contract and seasonal business demands as the auditwas carried out shortly before Christmas.

While most patients reported taking their medication,the numbers fall short of the standard of 80%. Respondentsdemonstrated a good understanding of how to take oradminister bisphosphonates, although they had less under-standing about avoiding some concomitant therapies andthe need to take them with plain water. It was encouragingthat pharmacists could offer counselling in 97% of inter-ventions, as counselling has been shown to increase patientcompliance with treatment. Recommendations include con-ducting pharmacist briefing and education evenings to dis-seminate audit results, and the distribution of leafletsexplaining bisphosphonate administration to pharmaciesfor patient use.

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The International Journal of Pharmacy Practice 2007; Supplement 2

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1 Scottish Intercollegiate Guidelines Network (SIGN).Management of osteoporosis (SIGN publication no 71).Edinburgh: SIGN; 2004.

2 Barat I, Andreasen F, Damsgaard EMS (2001). Drugtherapy in the elderly: What doctors believe andpatients actually do. Br J Clin Pharmacol 2001;51:615–22.

An audit of products available when required for dispensing by community pharmacists in Bedfordshire

K Mirza and EK Rosenbloom

Kings College, London, UK. E-mail: [email protected]

■ Community pharmacists in Bedfordshire conductedan audit to explore the issues, actions and associ-ated outcomes if a patient presents a prescriptionthat cannot be dispensed in full

■ Data were collected in 16 pharmacies for oneweek, and were centrally collated and analysedusing SPSS (v14)

■ Sixteen pharmacies dispensed a total of 19396items and owed 521 (2.7%) items; of these 309(59.3%) were part owed and 209 (40.7%) itemswere owed in full

■ The distribution and stock control system underpin-ning the prescribed medicine supply in the com-munity pharmacy setting is robust; failures areassociated with human error and requests forunusual or expensive items

Audit and reflective practice are components of clinicalgovernance, an essential community pharmacy service inEngland.1,2 In the community pharmacy setting, patients whopresent a prescription that cannot be dispensed in full are thenowed the outstanding balance. The aim of this audit was toexplore the issues, actions and outcomes when a patientpresents a prescription that cannot be dispensed in full. Theobjective was to support community pharmacists in undertak-ing a cycle of reflective practice.

The Watford community pharmacy group set the followingstandards for the audit as no standards had been predetermined:

• 80% of prescriptions are dispensed in full for patientsaged between 12 and 75 years of age

• no item is owed more than five times during the one-weekaudit period

• 90% or more of all prescription items for patients over theage of 75 years or children under the age of 12 yearsshould be dispensed completely

• 80% or more of all prescription items for patients betweenthe age of 12 and 75 years should be dispensed completely

• less than 90% of items dispensed should be owed due toincorrect stock levels.

• 98% of prescriptions for palliative care drugs should be sign-posted to an appropriate pharmacy or dispensed completely.

The audit tool was developed and sent to 30 community phar-macies in Bedfordshire who indicated that they would com-plete this practice audit within the stated timeframe. The auditwas completed over seven consecutive days during a 3-weekperiod during November 2006. Quantitative and qualitativedata collected were analysed using SPSS v14.

Of the 30 audits that were distributed, 21 were returned withinthe timeframe. and of these 16 were valid. All communitypharmacies passed each of the standards set. Pharmacies dis-pensed a total of 19396 items and owed 521 (2.7%) items. Ofthe 521 owed items, 309 (59.3%) were part owed and 209(40.7%) were owed in full. The main reason for an owed itemwere staff employed in the community pharmacy making aprocedural error associated with the ordering process; thisaccounted for 146 items (28%). Unusual items accounted for146 items (28%). All pharmacists who completed the auditindicated that the audit would inform practice. However, nopharmacist indicated that they would train their workforce.

The distribution and stock control system underpinningmedicine supply in the community pharmacy setting isrobust. This audit was able to inform community pharmacypractice. Community pharmacists should be encouraged toinclude both staff and patient issues in reflective practice.

1 Schon D. (1983) The reflective practitioner. London:Temple Smith, London; 1983. pp 49–52, 54–6, 61–3.

2 Anon. PSNC contract workbook 2005–2006, Essentialservices. Aylesbury: Pharmaceutical Services NegotiatingCommittee; 2005.

References

Focal points

Introduction

Method

Results

Discussion

References

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Clinical audit of reasons for stopping clozapine

A Arif1, P Douglas-Hall2, C Whittlesea1 and D Taylor2

1Department of Pharmacy, King’s College London, 150, Stamford Street, London SE1 9NH, UK and 2South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ, UK. E-mail: [email protected]

■ An audit was undertaken to determine the reasonsfor patients discontinuing clozapine therapy

■ Non-adherence was the most common reason inthis study for discontinuing treatment

■ Fatal bowel obstruction, a known side-effect ofclozapine, occurred in two patients

■ All staff should be reminded of the risk of clozapine-induced constipation to ensure patient monitoringand education are undertaken

Clozapine is an atypical antipsychotic drug used to treatpatients with schizophrenia who have been diagnosed astreatment intolerant or treatment resistant.1 Compulsory bloodmonitoring is a requirement of treatment because of thepotentially fatal risk of neutropenia and agranulocytosis.2

Despite its benefits in such patients, a previous study demon-strated that the number of patients discontinuing clozapine ishigh, with 30% stopping treatment in the first 6 months.3

The aim of the audit was to determine the reasons whypatients stopped taking clozapine at one hospital, part of theSouth London and Maudsley NHS Trust.

Following approval from the trust for the audit to take place,a data-collection form was developed and piloted. A retro-spective case note analysis of all patients who had discontin-ued clozapine treatment in the period March 4, 2002 toOctober 12, 2006, identified via the Maudsley Patient Journeyand Clozaril Patient Monitoring Service databases, wasundertaken over 6 weeks (October/November 2006). Datawere analysed using Microsoft Excel 2003.

Of the 186 patients receiving clozapine during the studyperiod, 89 (47.8%) patients (male = 56) had discontinued

treatment. The ethnic groups most represented were‘Caribbean’ (n = 23, 25.8%), ‘White British’ (n = 20, 22.5%)and ‘other Black’ (n = 15, 16.9%). Non-adherence was themain reason for discontinuing treatment (n = 52, 59.8%), with22 (42.3%) of these patients stopping within the first 2months. Eight patients had developed neutropenia, but nocases of agranulocytosis were identified. Ten patients(11.5%) had died while taking clozapine, and the cause wasdetermined from the case notes in six patients. Four of thedeaths with known causes were considered avoidable andincluded two related to bowel obstruction. Two patients diedfollowing an overdose of clozapine; however, it was notpossible to establish from the patients’ records if these wereaccidental or intentional.

Although blood monitoring is a compulsory requirement ofclozapine therapy, only eight patients in this study discon-tinued treatment because of neutropenia. Case reports havedescribed deaths from clozapine-induced constipation.4 Theresults from this audit also highlight the potentially fatal riskof clozapine-induced constipation leading to bowel obstruc-tion. Therefore all healthcare professionals need to be awareof this side-effect to ensure symptoms are monitored and toprescribe laxative preparations when appropriate. Health-care professionals should also encourage patients takingclozapine to use non-treatment options, e.g. exercise anddiet, to reduce constipation. Non-adherence was identifiedas the main reason for stopping therapy, with a number ofpatients discontinuing treatment within 2 months. This rein-forces the importance of healthcare staff providing informa-tion to patients at the start of therapy. Patients should beaware that the benefits of clozapine treatment may take up to12 weeks to develop, but that side-effects may occur frominitiation of therapy. Further evaluation to determine the rea-sons for non-adherence by patients taking clozapine couldbe undertaken.

1 Guidance on the use of newer (atypical) antipsychoticdrugs for the treatment of schizophrenia. London: NationalInstitute for Clinical Excellence; 2002.

2 Kane JM, Honigfeld G, Singer J, Meltzer H. Clozapine intreatment-resistant schizophrenics. Psychopharmacol Bull1988;24:62–7.

3 Hayhursh KP, Brown P, Lewis SW. The cost-effectivenessof clozapine: a controlled, population-based, mirror-imagestudy. J Psychopharmacol 2002;16:169–75.

4 Levin TT, Barrett J, Mendelowitz A. Death from clozapine-induced constipation: case report and literature review.Psychosomatics 2002;43:71–3.

Focal points

Introduction

Method

Results

Discussion

References

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Differences between UK schools of pharmacy in assessing pharmaceutical calculations in the first and final years of the MPharm degree

C Marriott, SA Coulman and DN John

Welsh School of Pharmacy, Cardiff University, Redwood, King Edward VII Ave, Cardiff CF10 3NB, Wales, UK. E-mail: [email protected]

■ The aim of the study was to describe assessmentcriteria for pharmaceutical calculations in the firstand final years of the MPharm degree in UK schoolsof pharmacy (SoPs)

■ Semi-structured interviews were conducted withacademic staff at 17 UK SoPs

■ UK SoPs take a number of different approaches tothe assessment of pharmaceutical calculations inthe first and final years of the MPharm degree,particularly with regard to the pass mark, thenumber of attempts allowed and whether the useof calculators is permitted

The Royal Pharmaceutical Society of Great Britain (RPSGB)introduced the requirement that a pharmaceutical calculationssection of the registration examination must be passed at 70%,without using a calculator;1 a minority do not pass this sectionand are not able to register as pharmacists.2 The aim of thestudy was to describe assessment criteria for pharmaceuticalcalculations in the first and final years of the MPharm degree,in UK schools of pharmacy (SoPs).

An individual with responsibility for teaching pharmaceuticalcalculations at each of the 21 SoPs with at least two cohortsof MPharm students was identified either from personalknowledge of a member of the research team or from informa-tion on the SoP website. With consent a semi-structured,audio-recorded telephone interview was conducted with eachparticipant, and the resultant verbatim transcripts were ana-lysed by coding and indexing the data.

Interviews with academics from 17 UK SoPs (81%) wereconducted in February/March 2007. Twelve SoPs stated they

had specific pharmaceutical calculations assessments in thefirst year of the MPharm degree (n = 17), and pass marksranged from 40% to 90% (Table 1). Eight SoPs did not per-mit the use of calculators in these assessments, and thenumber of resit attempts also varied. Nine SoPs stated thatpharmaceutical calculations were assessed in the final year(n = 15). Of the six SoPs who reported a pass mark for thisassessment, it was variable (four had a pass mark of 70%,none of which permitted calculator use; one had a pass markof 50% without use of a calculator and the other SoP stated apass mark of 40–50% and permitted the use of calculators).The number of additional attempts for those failing the initialassessment varied between SoPs (n = 6) from one to ‘several’attempts.

Not all SoPs appear to require MPharm students to reach thesame standard in pharmaceutical calculations. Our findingsindicate that some students may graduate after achieving 40–50% in a final year calculations assessment. It is in the inter-est of public safety that pharmacists are competent at per-forming calculations, and as a healthcare regulator theRPSGB has a duty to protect the public, and as such requiresa pass mark of 70% for the calculations section of the regis-tration examination.1 It would be useful to establish whichapproaches to the assessment, and associated learning andteaching strategies, are more successful in terms of students’confidence and competence at performing pharmaceuticalcalculations.

The authors are extremely grateful to the participants for theirtime and co-operation.

Focal points

Introduction

Method

Results

Discussion

Acknowledgements

Table 1 First year pharmaceutical calculation assessments in schoolsof pharmacy

Pass mark (%) SoP (n) Calculator permitted

Yes No Not stated

40 1 1 40–50 2 2 50 2 2 70 7 2 5 80 1 1 90 1 1 Not stated 3 1 1 1

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1 RPSGB Registration examination guidance notes.www.rpsgb.org.uk/pdfs/preregexamguid.pdf (accessedJune 14, 2007).

2 Anon. Pass rate 86.5% in registration examination. PharmJ 2006;7411:141.

Obtaining the views of the public on gene therapy: what questions need to be asked?

JC Oswald, DN John and JC Birchall

Welsh School of Pharmacy, Cardiff University, Redwood, King Edward VII Ave, Cardiff CF10 3NB, Wales, UK. E-mail: [email protected]

■ The aim of the study was to identify issues relatingto gene therapy that may be used to developmaterials for use in focus groups involving thepublic

■ Key informant interviews with eight individualswith an interest in gene therapy (scientist, clinicianand lay) were conducted

■ Study participants identified several themes whichthey considered important to explore with mem-bers of the public

Gene therapy approaches are currently being investigated foruse in a diverse range of conditions, for example, certaincancers, Parkinson’s disease and combined immunodefi-ciency (SCID).1 Gene therapy is important to pharmacy asincreasing numbers of gene therapies are being developedand used in practice,2 although in a recent study a sample ofpharmacists and pharmacy students were not familiar withgene therapy.3 There has been some work reporting publicviews and involvement in developing new health technologies,4

although members of the British Society for Gene Therapy(BSGT) indicated (personal communication) that the BSGTwould welcome the views of the public on issues relating togene therapy in particular. The aim of the study was to identifyissues relating to gene therapy that may be used to developmaterials for use in focus groups involving the public.

Key informant exploratory, semi-structured interviews wereconducted with expert scientists, clinicians and informed laypeople (n = 8) including two committee members of theBSGT. Each contact was known by one of the authors with aresearch interest in gene delivery (JCB). Semi-structuredinterviews were used as they allow coverage of key pointswhile also providing flexibility so other interesting issues canbe explored, and for clarification purposes. Participants wereasked what information and views relating to gene therapywould be useful to obtain from public focus groups. Follow-ing audio-recording, verbatim transcripts were analysed bycoding and indexing the data.

Issues raised by the respondents on which they would likeviews of the public included public understanding of whatgene therapy is; from which sources have they been madeaware of gene therapy; for what conditions might gene ther-apy be useful; perceived benefits; perceived risks, concernsand potential dangers; what information would they want orneed to know and in what format; attitudes towards genetherapy; ethical issues; what issues do they want scientificand health communities to address; potential availability oftreatment and advice. The interview subjects were interestedin a range of positive, negative and uncertain views beingobtained, as well as the views from those who have personalexperience of where gene therapy might have a role and thosewho do not have such experiences. Further, it was suggestedthat educational background, sex and age group, amongothers, may have helped form key informants’ views and theperspectives from which they spoke.

This approach was useful in determining a number of issuesfor discussing with members of the public about gene therapy,which would not have been identified from the literaturealone. These key informants welcomed the opportunity tohelp in the development of the public engagement agenda ingene therapy, and are interested in receiving the results of thefocus group discussions. This information will now be usedto develop materials for use in focus groups involving thepublic.

The authors are extremely grateful to the participants for theirtime and co-operation.

References

Focal points

Introduction

Method

Results

Discussion

Acknowledgements

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1 Twisselmann B. Gene therapy. BMJ 2003;326:506. 2 Simpson J. Progress in gene therapy – are hospital phar-

macies the next barrier? Hosp Pharm 2006;13:266. 3 Yousif S, Gorecki DC. Are pharmacists ready for gene

therapy? Pharm J 2004;272:159–62. 4 Bates BR. Public culture and public understanding of

genetics: a focus group study. Public Underst Sci2005;14:47–65.

Ensuring safer practice with high-dose ampoules of diamorphine and morphine: the Colchester response

OL Eradiri, RJ Needle, A Wood, E Idowu and L Notley

Essex Rivers Healthcare NHS Trust, Colchester General Hospital, Turner Road, Colchester CO4 5JL, UK. E-mail: [email protected]

■ The work demonstrated the trust’s compliancewith the National Patient Safety Agency’s (NPSA)notice to NHS organisations on the safe use ofhigh-dose opioids

■ The process heightened awareness on the safe useof opioids by all clinicians, and produced simplebut effective ‘gates’ to minimise risk

■ The audit results show that the trust was broadlycompliant, and is benefiting from the additionalsafety measures now in place

In May 2006, the NPSA issued Safer practice notice 12 toprevent deaths from the use of high-dose ampoules ofmorphine and diamorphine.1 In particular, the notice requiredseparate storage and distinction for the high-strength(≥30 mg) ampoules and the availability of naloxone in allclinical areas where opiates were administered. In response,the Medication Safety Group at Essex Rivers HealthcareTrust in Colchester, in July 2006, produced an action plan,2

and set up a multidisciplinary working party comprising con-sultants, nurses and pharmacists. This party was tasked withevaluating current protocols and practices in the trust’s use ofopioids, in respect of prescribing, handling, administrationand monitoring.

The working party reviewed and updated relevant therapeu-tic guidelines, highlighting equivalence between opioids,3

and emphasising dose titration. Parenteral administrationprotocols were reviewed, and emphasis was placed on moni-toring (especially for patients receiving opioids for the firsttime) and remedial measures. Patients were also to beinformed of side-effects to expect. A section on safe use ofopioids was included in the Intravenous administration train-ing day for nurses. Pharmacy reviewed the usage figures ofmorphine and diamorphine in the last 12 months, andrestricted stock holdings to critical care and palliative careareas only. All other areas requested supply on a named-patient-only basis. The high-dose ampoules were distin-guished by red sticker labels with the inscription ‘WARN-ING – High-strength opioid’, and stored separately in thecontrolled drug cabinet in the dispensaries and on the wards.The availability of the opioid antagonist naloxone wasensured in all areas holding opioids (low and high strengths).Using existing trust-wide information cascades, the similari-ties in packaging and risk of error with opioids was commu-nicated to all clinical staff.

An audit tool was designed to monitor compliance with setstandards, and all clinical areas were audited 3 months afterthe last change was implemented.

The usage figures in the preceding 12 months were (no of vials):diamorphine 30 mg (462), diamorphine 100 mg (181), andmorphine sulphate 30 mg (40). Of these, 76% were by pallia-tive care and 6% by critical care. Using the audit tool,35 wards were visited once only in the period December 4–8,2006. There was 100% compliance with the standard torestrict stock to palliative and critical care areas; there was100% compliance with the standard on naloxone availability,but there was only 75% compliance with the standard on redsticker labels. No wards had named-patient supplies of high-strength opioids that week.

The action plan was implemented within 3 months. The trustis now fully compliant with the National Patient SafetyAgency (NPSA) Safer practice notice 12. Responding to thenotice was a very useful and positive experience, as it neces-sitated the engagement of all clinical groups on a medicationsafety issue. Furthermore, it was evidence for the dictum thatmeasures to effect safety do not have to be expensive.Increased medication awareness and patient safety have beenthe consequence. Work is ongoing to ensure 100% compli-ance with the red warning label by pharmacy.

References

Focal points

Introduction

Method

Results

Discussion

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1 National Patient Safety Agency (NPSA). Safer practicenotice 12. www.npsa.nhs.uk (accessed June 14, 2007).

2 Medication Safety Group. Essex Rivers Healthcare Trust.Action plan for NPSA Notice 12: ensuring safer practicewith high dose ampoules of diamorphine and morphine.Colchester: Essex Rivers Healthcare Trust; 2006.

3 Essex Rivers Healthcare Trust. Opioid conversion chart.Colchester: Essex Rivers Healthcare Trust; 2006.

Preventing drug-related admissions: potential cost savings for a health economy

JC Scanlan1, GP Price1, C Gidman2, M Knass2, H Bianchi3, A Hodgson4

1East Cheshire NHS Trust, Victoria Road, Macclesfield, Cheshire SK10 3BL, UK, 2Central and Eastern Cheshire PCT, Bevan House, Barony Road, Nantwich CW5 5QU, UK, 3Cumberland House Surgery, Waters Green Medical Centre, Sunderland Street, Macclesfield SK11 6JL, UK and 4Andrews Pharmacy, 8 Westmoorland Close, Upton Priory, Macclesfield SK10 3ET, UK. E-mail: [email protected]

■ The aim of the study was to determine the numberof preventable drug-related admissions to a smalldistrict general hospital

■ 48% of admissions are as a result of a drug-relatedproblem; 44% of these are due to treatment failureor suboptimal therapy, and 40% are due toadverse effects

■ The savings associated with preventing theseadmissions are between £0.5 and £2million perannum

The government has stated that care should be delivered topatients in the primary care setting and that hospital admis-sions should be reduced by 5% by 2008.1,2 It is therefore per-tinent for organisations to consider how this might beachieved. Previous studies have shown that many admissionsare drug related.3 Potentially avoidable causes of drug-relatedadmissions include non-compliance with the prescribed regi-men, adverse effects, inadequate follow-up, with particularreference to adequate monitoring and suboptimal treatmentregimens.

In the 2001 census, 23% of the population of easternCheshire were 60 years of age or older. This is higher than thefigure for England and Wales, which in 2001 was 20%. It ispredicted that by 2010 the number of over 60s in the easternCheshire locality will increase by a further 20%. Althoughpeople are living longer, they are not remaining healthy. Aconsequence of an aging population is that more people havelong-term conditions. These conditions require treatment withdrug therapy which, if not used optimally, can be the cause ofa hospital admission.

The aim of this project was to determine the number ofpotentially avoidable drug-related admissions to a small dis-trict general hospital with a higher-than-average elderlypopulation, and to quantify this as a potential cost saving forthe health economy.

Two pharmacists and one F2 doctor assessed all patients whowere admitted via the medical admissions unit at East Chesh-ire NHS Trust over a 1-week study period. A standardisedmethod of assessing drug-related problems (DRPs) wasdeveloped. Patients were categorised according to the occur-rence of a DRP. Patients were classified as experiencing adefinite DRP, a possible DRP or no DRP. A DRP was definedas the patient suffering a side-effect of their medicationregimen, suboptimal therapy, treatment failure, overdose,non- or poor compliance, or a side-effect as a result of a druginteraction.

One-hundred and eight patients were assessed during thestudy period. Fifty-two per cent of the patients experiencedno DRP, 26% experienced a definite DRP and 22% a possibleDRP. In total, 48% of admissions during the study periodwere due to DRPs. The nature of the DRPs were side-effects(40%), suboptimal therapy (27%), treatment failure (16.5%),overdose (9%), non-/poor compliance (5.5%), and drug inter-action (2%). The admission rate and population spread duringthe period of data collection was consistent with other timesduring the year.

Prevention of all 48% of the DRPs would save the health eco-nomy £2million per annum. This is based on hospital costsalone. It is acknowledged that all DRPs are not preventable,so a more conservative estimate would be a saving of£0.5million per annum. The limitations of the study periodshould be considered. However, this information is to be usedto develop a joint acute and primary care trust pharmaceuticalcase management programme in order to specifically addressthese identified needs.

References

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Method

Results

Discussion

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1 Our health, our care, our say. London: Department ofHealth; 2006.

2 Supporting people with long-term conditions. London:Department of Health; 2005.

3 Pirmohamed M, James S, Meakin S et al. Adverse drugreactions as cause of admission to hospital: prospectiveanalysis of 18820 patients. BMJ 2004;329: 15–19.

References