The Consequences of Missed Medication Doses Laura Bucknell Lead Pharmacist Gloucestershire Care Services

1. The Consequences of Missed Medication Doses Laura Bucknell Lead Pharmacist Gloucestershire Care Services

2. In February 2010 The National Patient Safety Agency issued a Rapid Response report highlighting the issue of missed or delayed medicines. Why did they do this – it may seem only a minor issue if Mr Jones misses a dose of his diuretic or Mrs Smith doesn’t start her antibiotics until the next day but for some poorly patients and some critical medicines these delays or omissions can cause serious harm or death In February 2010 The National Patient Safety Agency issued a Rapid Response report highlighting the issue of missed or delayed medicines. Why did they do this – it may seem only a minor issue if Mr Jones misses a dose of his diuretic or Mrs Smith doesn’t start her antibiotics until the next day but for some poorly patients and some critical medicines these delays or omissions can cause serious harm or death

3. Actions List of ‘critical medicines’ Appendix to POPAM Ensure appropriate supply systems both in and out of hours The RRR highlighted actions that all health organisations must put in place Compile a list of critical meds Ensure appropriate guidance for staff Ensure appropriate supply procedures Full list is available as an appendix to POPAM but includes: The RRR highlighted actions that all health organisations must put in place Compile a list of critical meds Ensure appropriate guidance for staff Ensure appropriate supply procedures Full list is available as an appendix to POPAM but includes:

4. Critical Medicines Antibiotics/ antifungal Anticoagulants Resus medicines Insulin Anti-parkinsons drugs The full list is available as an appendix to POPAM but key groups included in this list are;The full list is available as an appendix to POPAM but key groups included in this list are;

5.  Consequences! Patient admitted with infected ulcer and cellulitis. Seen by doctor at 3pm, instruction to commence IV antibiotics Busy ward, not usual drug round time, nurse distracted and antibiotics not given That evening patient admitted to ICU Died from sepsis These are not local examples but they are real examplesThese are not local examples but they are real examples

6.  Consequences! Patient diagnosed with PE LMWH prescribed Not administered Patient died

7. Extreme examples BUT Delay/hinder recovery Worsening of condition Potentially increased interventions Increased length of stay Poor patient experience Increased cost These are very extreme examples but not even for less critical drugs or when patients are not in an acute setting there are consequences of delaying or not administering medsThese are very extreme examples but not even for less critical drugs or when patients are not in an acute setting there are consequences of delaying or not administering meds

8. Medication for people with Parkinsons Disease If people with Parkinsons don't get their medication on time, their ability to manage their symptoms may be lost, they may suddenly not be able to move, get out of bed or walk. Many drugs for treatment of Parkinsons are required to be given very frequently (up to 5 times a day)

9. Local Initiatives Flagging system on notes to alert staff to these patients Use of hand over to remind/raise awareness Use of alarm clocks/timers to remind staff Patient prompts nursing staff Self medication

10. Parkinsons Disease Society Have launched campaign called ‘Get it on Time’ On their website have a section aimed at care home staff caring for patients with parkinsons www.parkinsons.org.uk Get it on Time is aimed at hospital healthcare staff to reinforce the importance of patients with the disease receiving their medicines on timeGet it on Time is aimed at hospital healthcare staff to reinforce the importance of patients with the disease receiving their medicines on time

11. Productive Ward Initiative Initiative from NHS Institute for Innovation and Improvement Gloucestershire CS currently undertaking the medicines module Aim to minimise interruptions and streamline the administration process OTHER LOCAL INITIATIVES: The Productive Series is an initiative from the NHS Institute for Innovation and Improvement that supports NHS teams to redesign and streamline the way they manage and work.  The aim is to achieve significant and lasting improvements – predominately in the extra time that staff can give to patients by streamlining and making processes lean and effective, as well as improving the quality of care delivered and reducing costs. The Productive Series has adopted efficiency techniques previously used in private manufacturing industries and have adapted them for the NHS Gloucestershire Care Services is full involved in the productive seriesThe key to the success of The Productive Series is that improvements are driven by staff themselves, by empowering them to ask questions about practice – why do we do it that way? The answer – because that is the way we have always done it – is not good enough . So asking these questions empowers staff to make positive changes to the way they work.  The process promotes a continuous improvement culture leading to real savings in materials, reducing waste and improving staff morale Productive Community Hospitals is a national initiative and as GCC have already completed (award winning!) work on Handovers and MDT working which was piloted by one ward within the county and then this evidenced best practice was shared with and is being adopted by the other wards. Currently looking at Medicines Module in two wards within one of our CHs. The aim of this part of the programme is to reduce the other activities that Nurses end up doing during a medicines round –particularly to minimise interruptions by Ensuring everything that is required for the round is there ( including the patients)! This allows the focus to be on quality, safety, patient and staff satisfaction and an effective use of nursing time. Not going to go into much more detail as talking about the productive series could be a whole presentation on its own but it is hoped that the learning from this will help to minimise missed/delayed doses by minimising interruptions and streamlining the ward round. Then this learning will be rolled out across all our community hospitals OTHER LOCAL INITIATIVES: The Productive Series is an initiative from the NHS Institute for Innovation and Improvement that supports NHS teams to redesign and streamline the way they manage and work.  The aim is to achieve significant and lasting improvements – predominately in the extra time that staff can give to patients by streamlining and making processes lean and effective, as well as improving the quality of care delivered and reducing costs.

12. Medication Administration Chart Audit carried out in April 2010 11% of regular prescribed medications were not annotated as given or a suitable alternative notes (i.e. they were blank) Equates to 115 drug administrations!! In April 2010 we carried out a full medication chart audit across all our community hospital sites. One of the things which was highlighted in this was the number of blank administration records! That could mean 3 things 1. 11% of all regular prescribed medication was not given to patients during the period of the audit. As I already mentioned – the potentially consequences for patients !! 2. all the medication was given but 11% of administrations were not recorded . 3. A combination of the 2 What ever the reason – it is not RIGHT!! In April 2010 we carried out a full medication chart audit across all our community hospital sites. One of the things which was highlighted in this was the number of blank administration records! That could mean 3 things 1. 11% of all regular prescribed medication was not given to patients during the period of the audit. As I already mentioned – the potentially consequences for patients !! 2. all the medication was given but 11% of administrations were not recorded . 3. A combination of the 2 What ever the reason – it is not RIGHT!!

13. Contact staff on previous drug round -TIME Additional observations on patient -TIME Contact the prescriber -TIME Complete an incident form -TIME Potential delay of the next dose! POPAM NMC Standards for Medicines Management If you are the nurse carrying out the next drug round and you are faced with the blank administration chart- what do you do? You have to waste precious nursing time trying to establish if the medicine has been omitted or administered and just not recorded. If a shift change staff will no longer be on site – TIME If you can’t establish if the medicine has been omitted or given or actually manage to establish it has not been given then you may need to carry out additional observations on the patient-TIME Possibly contact the doctor – TIME Complete an incident form _TIME If you are the nurse who has not completed the administration chart consider the impact your action (or actually inaction) has had on the rest of your colleagues!! Over and above the time issue and the impact on patients and colleagues not completing the administration chart is in breach of POPAM and the NMC Standards for Medicines Management If you are the nurse carrying out the next drug round and you are faced with the blank administration chart- what do you do? You have to waste precious nursing time trying to establish if the medicine has been omitted or administered and just not recorded. If a shift change staff will no longer be on site – TIME If you can’t establish if the medicine has been omitted or given or actually manage to establish it has not been given then you may need to carry out additional observations on the patient-TIME Possibly contact the doctor – TIME Complete an incident form _TIME If you are the nurse who has not completed the administration chart consider the impact your action (or actually inaction) has had on the rest of your colleagues!! Over and above the time issue and the impact on patients and colleagues not completing the administration chart is in breach of POPAM and the NMC Standards for Medicines Management

14. Reasons for omitted medicines Medicine not prescribed Medicines not available Patient not on ward Forgot to administer Unfamiliar with medicine Why are medicines omitted? Could be a number of issues but the most common reasons are listed Medicines not prescribed. This could occur when a drug chart is written on admission or rewritten and something is missed off or sometimes when a new treatment is not prescribed – often with short courses such as antibiotics. Highlights the importance of a comprehensive hand over A slight aside but related to this is process some of you hopefully will have heard of – Medicines Reconciliation. The aim of medicines reconciliation is to ensure that the medicines prescribed for a patient on admission correspond to those they were taking before admission. Meds rec sounds very complicated but it is simply about getting medicines RIGHT! It may sound simple but very often errors occur at this stage which result in omitted medicines during an inpatient stay and sometimes the other way with medicines being given which should not be This is a nationally recognised problem which has had its profile raised by a joint publication by NICE ( National Institute of Clinical Excellence and the NPSA ( national Patient Safety Agency) issuing a requirement for Meds rec to take place on admission of adult patients to inpatient units. Gloucestershire Care Services is part of the South West Community Quality and Patient Safety Improvement Program led by the SHA. This is an ambitious program to improve patient safety and is looking at a number of key areas Prevention of VTE (venous thromboelmbolism_ Pressure ulcers Recognising the deteriorating patient Catheter associated UTIs Falls Leadership Medicines management In the first instance the Medicine Management aspect is medicines reconciliation so any care service community hospital staff will be hearing a lot more about it in the neat future! Why are medicines omitted? Could be a number of issues but the most common reasons are listed Medicines not prescribed. This could occur when a drug chart is written on admission or rewritten and something is missed off or sometimes when a new treatment is not prescribed – often with short courses such as antibiotics. Highlights the importance of a comprehensive hand over A slight aside but related to this is process some of you hopefully will have heard of – Medicines Reconciliation. The aim of medicines reconciliation is to ensure that the medicines prescribed for a patient on admission correspond to those they were taking before admission. Meds rec sounds very complicated but it is simply about getting medicines RIGHT! It may sound simple but very often errors occur at this stage which result in omitted medicines during an inpatient stay and sometimes the other way with medicines being given which should not be This is a nationally recognised problem which has had its profile raised by a joint publication by NICE ( National Institute of Clinical Excellence and the NPSA ( national Patient Safety Agency) issuing a requirement for Meds rec to take place on admission of adult patients to inpatient units. Gloucestershire Care Services is part of the South West Community Quality and Patient Safety Improvement Program led by the SHA. This is an ambitious program to improve patient safety and is looking at a number of key areas Prevention of VTE (venous thromboelmbolism_ Pressure ulcers Recognising the deteriorating patient Catheter associated UTIs Falls Leadership Medicines management In the first instance the Medicine Management aspect is medicines reconciliation so any care service community hospital staff will be hearing a lot more about it in the neat future!

15. Medicine not available? Poor communication Responsibility Options PODs Pharmacy Emergency cupboard Borrow from another ward FP10 to local pharmacy Prescriber to review medication Medicines may not be available for a number of reasons and particularly for our community hospitals which do not have onsite pharmacies, obtaining supplies quickly is not always possible. One key issue which we must address is when supplies of medication for inpatients run out and are not reordered in a timely fashion- maybe a situation of everyone assuming that someone else will do it!! Never assume – you know what they say !!!Medicines may not be available for a number of reasons and particularly for our community hospitals which do not have onsite pharmacies, obtaining supplies quickly is not always possible. One key issue which we must address is when supplies of medication for inpatients run out and are not reordered in a timely fashion- maybe a situation of everyone assuming that someone else will do it!! Never assume – you know what they say !!!

16. Next steps? One step at a time Raise awareness Learn from the experience of our productive series pilot Adapt and roll out Empower staff Audit So what are the next steps to address missed doses? Well it will be one step at a time- it is a bit like eating an elephant- you aint going to do it in one bite! Raise awareness So what are the next steps to address missed doses? Well it will be one step at a time- it is a bit like eating an elephant- you aint going to do it in one bite! Raise awareness

17. National Patient Safety Agency (NPSA) www.npsa.nhs.uk Parkinsons Disease Society www.parkinsons.org.uk NMC Standards for Medicines Management www.nmc-uk.org Standards for Medicines Management – really good tool Can be downloaded off the website or ordered as hard copy free of charge- it contains the MINUMIM standard for MM practice and I would encourage you all to look at itStandards for Medicines Management – really good tool Can be downloaded off the website or ordered as hard copy free of charge- it contains the MINUMIM standard for MM practice and I would encourage you all to look at it

18. Thank you for listening Any questions?