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Theory into practice


Laurence A Goldberg FRPharmS
Editorial Consultant

Medication errors are common and opioids, in particular, morphine are often involved, Roger Knaggs (advanced pharmacy practitioner in pain management, Nottingham University Hospitals Trust) told the audience at a satellite meeting of the United Kingdom Clinical Pharmacy Association (UKCPA) Pain Management Group. There has been a steady increase in opioid prescribing – from 300,000 doses per month in June 2007 to 500,000 doses per month in December 2008 and newspaper reports about adverse events have heightened concern about opioids. These have included reports of accidental diamorphine overdoses and warnings about the dangers of over-the-counter (OTC) codeine. Concerns have also been voiced in the professional press – articles in the British Medical Journal have questioned the appropriateness of opioid use and commented on the lack of evidence for benefit when opioids are prescribed for musculo-skeletal pain, he continued.

Data from the National Patient Safety Agency (NPSA) show that opioids, usually morphine, cause more deaths and severe harm than all other medicines. Confusion between formulations of morphine sulphate tablets was the cause of one reported incident and a survey showed that 76% of palliative care physicians reported having patients who had confused normal and modified release formulations. Furthermore, on 43% of the occasions when either a patient or a pharmacist had selected the incorrect opioid formulations, serious undesirable effects, including some that required hospital admission, had occurred.

Problems with opioids result from difficulties with dose calculations, similar sounding names and the availability of a wide range of products with differing potencies and release characteristics. Dr Knaggs said that in total there were seven immediate-release products in five strengths and 26 modified-release products in 12 strengths. Dose conversions can be a particular problem area as people do not always realise that small variations can make a big difference at high dose levels. Buprenorphine and fentanyl lie at opposite ends of the potency spectrum. Errors with fentanyl are not uncommon because of a lack of awareness of its potency. It is not unusual to see patients receiving transdermal fentanyl 25mg per hour, who, when admitted for surgery, have their dose increased to 200mg per hour – a dose equivalent to 800mg morphine per day, said Dr Knaggs.

Safer practice notices from the NPSA have identified the risks and set out clear guidance for action, however, reports of adverse events have continued and other safety initiatives are needed. One proposal was to add death or serious injury arising from opioid overdoses to the NHS list of ‘never events’. Never events are serious, largely preventable incidents that should not occur if the available prevention measures have been implemented by healthcare providers.

Joint working offers a multidisciplinary approach to opioid management that expands awareness of the risk in opioid use and ensures consistency of guidance to minimise risks, according to Ian Bourns (director of medicines management and pharmacy, East Sussex Hospital NHS Trust). Other benefits are that awareness of best practice can be raised and that the range of opioid preparations can be limited, and the risks of confusion between products thereby reduced. Mr Bourns described how collaborative working between the hospital pharmacy personnel and Primary Care Trust pharmacy personnel has made this possible in his area. Working together with hospice and palliative care experts, and acute and chronic pain specialists, they have compiled a local formulary and best practice guidance that reflect local preferences.  The resulting package has been built into the existing prescribing and medicines use support systems. Most importantly, the guidance has been published repeatedly in local newsletters for hospital staff and for GPs.

Mr Bourns concluded that joint working is always good practice but it requires mutual trust and some personal risk-taking. In order to be successful, guidance needs to be area-wide rather than only applicable to a single institution and guidance should be fed into existing joint communications and decision support systems.

Medicines management
A study conducted in Bristol by Alison Mundell (Pharmacy Department, North Bristol NHS Trust) showed that for 55% of patients discharged from hospital with ‘red traffic light’ (RTL, high alert) medicines, the GP had no record. RTL medicines are generally ‘hospital only’ medicines that cannot be prescribed by GPs but can be part of a patient’s regular treatment. A random sample of 210 prescriptions for 26 different high-risk RTL medicines written in December 2009 was followed up after a period of eight to 12 weeks. High-risk RTL products were defined as drugs that could interact with a number of other medicines or that would pose a risk if not prescribed e.g. chemotherapy. The results showed that in 116 cases the GP had no record of the prescription. Items omitted in this way included infliximab, rituximab, vincristine, zoledronic acid and ciclosporin. Ms Mundell concluded that medicines omitted from the GP summary would be missed during the medicines reconciliation process if a patient were admitted to hospital. David Cousins (Head of Safe Medication Practices, National Patient Safety Agency, London) commented that many GP prescribing systems do not have a place for ‘hospital-only’ medicines and in others ‘hospital-only’ medicines are not linked to the decision support system and so they can easily be overlooked. Whilst it is appropriate to ensure that GPs have this information, they also need the systems to enable them to make use of it and this will require work with the vendors of GP prescribing systems, he added.

A study conducted at Guy’s and St Thomas’ NHS Foundation Trust showed that 82% of medicines administration rounds were interrupted at least once. (Alice Oborne, Elizabeth Stewart and Jo Philips, Pharmacy Department, Guys and St Thomas’ NHS Foundation Trust, London.) This is important because a previous study has shown that each interruption increases the risk of administration error by 12–13%. The researchers observed 49 medication administration rounds and recorded 75 interruptions – a mean rate of 1.5 interruptions per round. The most common reasons for interruption were clinical queries from other staff or patients, requests for assistance and missing equipment and medicines. Almost 30% of interruptions came from patients. A further 16% of interruptions were coded as ‘chatting’ and 10% were recorded as non-clinical. Almost half the interruptions resulted in the nurse being distracted from her task for up to three minutes. The researchers commented that the rate of interruption suggests a lack of understanding of the importance of medication administration and the potentially deleterious effects of interruptions. They noted that other investigators have suggested that staff view medication administration as a mundane function and even take a pride in the ability to multitask while administering medication. They concluded that strategies to reduce interruptions should now be tested. The use of coloured tabards and red rubber gloves as a visible warning against interruption is under consideration.

“Beware of fashionable pessimism, apprehension about change and nostalgia for times past,” Duncan Craig (Professor of Pharmacy, University of East Anglia) told the audience. In fact the current undergraduate pharmacy degree in the UK is now better than ever and at the University of East Anglia pharmacy practice is attracting more funding that all the other research teams, he continued.

Since it was founded in 2007 the University of East Anglia (UEA) has found a place in the world top 200 universities and has been the top UK pharmacy school in national surveys for the past four years. It has achieved this by being research intensive and by developing of culture of mutual respect and solid professionalism, believes Professor Craig.

There are a number of popular myths about university education. The first is that ‘students want only relevant material’. If this were the case then law and practice would be the most popular items in the timetable. What students really want is contextualisation and they readily understand that basic science concepts lead to clinical science and then to direct patient care, he argued. The second myth is that students do not like science or anything that is conceptually difficult. In fact there is no correlation between the relevance of a subject area and students’ evaluations  – they like logical explanations. The third myth is that the pharmacy degree exists exclusively train pharmacists. Professor Craig argued that the degree should educate students in a scholarly manner and not merely produce ‘grey professionals’.

Pharmacy is the only degree that combines hard science with clinical applicability. Medical studies do not, he said. As a result, it produces graduates who are experts in drugs and medicines. The UEA course incorporates workshops, problem-based learning, hospital placements and reflective evaluations. There is a large element of interprofessional learning where pharmacy and medical students mix. Management skills are also taught and special options include topics such as veterinary medicines and unlicensed medicines. One valuable development at UEA has been the use of screencasts where videos of the difficult parts of a lecture are posted on the intranet so that student can replay then as often as needed. Students have reported that these are particularly useful.

Summing up Professor Craig argued that pharmacists should provide scientific leadership and position themselves as the people to consult about medicines’ issues. “Practice is science,” he emphasised and we should say it more often and not feel diffident about it.

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