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Aspiring to clinical excellence


Christine Clark BSc, MSc, PhD,
FRPharmS, FCCP(Hon)
Editor, HPE

Everyone makes errors and technology can help or hinder the process, according to Harold Thimbleby (Professor of Computer Science at Future Interaction Technologies, University of Wales, Swansea). A fatal event that took place at the Alberta Cancer Center in 2006 illustrated the point. A patient was prescribed a four-day infusion of 5-fluorouracil as part of a cancer treatment regimen. When calculating the administration rate for the intravenous pump the nurses made a calculation error that resulted in the patient receiving a 24-fold overdose.
When the incident was investigated, it was reported that nurses found the pump, the programming process and the decimal point in the dosage instructions confusing.

Investigators concluded that nurses needed better training but Professor Thimbleby argued that the intravenous pump was inadequate for the job. The nurses were given “a mass of numbers” from which it was difficult to extract what was needed. In addition, a nine-step calculation with 22 keystrokes was required to determine the infusion rate, but the pump calculator could not alert the user to an error.  The pharmacy knew the correct administration rate but the overall system was poor, he said.

The design of computerised systems is critical because poor design can delay effective treatment as was seen with one system that would not allow emergency treatment to commence until patients had been fully registered. In this case the 30-minute delay that was introduced led to an increase in deaths.

A good example of design is pumps or devices that use up and down keys to adjust dose rather than a numerical keypad. Up/down keys, which force the user to focus on the number, are twice as good at detecting errors, said Professor Thimbleby. In one case a patient died after receiving a drug at 55mg per hour instead of 5.5mg per hour. This could have arisen from a ‘key-bounce’ error that the user had tried to correct but the device had responded by changing the dose to 55mg/hour, he suggested.

We all make slips; bad design can double the fatality rate and good design can halve it. Wiser choices in devices could save lives, he concluded. 

Electronic prescribing
Electronic prescribing (e-prescribing) can deliver tangible benefits, Ann Slee (Director of Pharmacy, University Hospitals Birmingham NHS Foundation Trust) told the audience. Describing the PICS (prescribing information and communication system) that had been developed for University Hospitals in Birmingham, she said that the system is now live on more than 500 tablets and 4000 desktop computers in 54 wards. The paper-free system covers both prescribing and administration of oral medicines and injectable medicines including infusions and chemotherapy.

The benefits of e-prescribing include paperless management of prescribing with in-built, real-time checks on drugs, routes, contra-indications and interactions. In addition, the system can be accessed from almost anywhere in the hospital and there are opportunities for formulary management measures. Systems may or may not also support production of discharge letters and an interface with the pharmacy system, explained Ms Slee. In her hospital, clinical observations are all electronic and can be linked to prescribing support, she added. Unfortunately, e-prescribing cannot eliminate prescribing errors or guarantee good practice but it can support quality initiatives. New types of medication errors have emerged, such as mis-selection errors when choosing from a menu. 

In addition, ‘work-arounds’ and poor practice are much more visible with e-prescribing. For example, if a prescriber is tempted to reproduce all in-patient medicines on the discharge prescription, this is immediately obvious. The system cannot optimise prescribing or tell you that the patient has the right medicines, said Ms Slee. The system should identify errors such as daily (instead of weekly) dosing of methotrexate but already one error had been identified in which a patient was prescribed 2.5mg methotrexate daily. On investigation it turned out that the computerised system alarmed if the weekly dose exceeded 25mg.

The challenge of keeping up to date is an issue with all computerised systems and feedback from users is critical for this. One helpful feature is the clinical dashboard that presents performance as a series of dials that show both departmental and overall performance in key areas. For example, missed antibiotic doses were running at a level of 10% in January 2008. After presenting the dashboard to clinicians there was a sudden but modest fall; after the Trust chief executive started to attend meetings where data were presented there was a sudden much larger fall in the rate of missed doses. The Trust is looking into a structured antibiotic prescribing scheme, said Ms Slee. Another useful innovation was the automatic prescribing (by the system) of antibiotics for decolonisation when MRSA is identified, she added.

In summary, e-prescribing is not a panacea for prescribing error and it increases pressure on the pharmacy department. However, it also improves accessibility and communication and provides the opportunity to measure
and monitor quality improvements
she concluded.

Consultant pharmacists
The role of the consultant pharmacist needs to become embedded into the professional fabric, Philip Howard (Consultant Antimicrobial Pharmacist, Leeds Teaching Hospitals NHS Trust and Chair, Consultant Pharmacists Group) told the audience. A framework for consultant pharmacists was introduced in 2005 with the aims of ensuring that the highest level of pharmaceutical expertise was available to the patients who needed it and to make the best use of high-level pharmacy skills in patient care. It was also envisaged that this would strengthen professional leadership and provide career opportunities that would help to retain experienced pharmacists in practice. NHS organisations were encouraged to develop consultant pharmacist posts across a broad range of services and local needs. The main areas of activity for consultant pharmacists are expert practice, research, evaluation and service development, education, mentoring and overview of practice, and professional leadership, he explained.

There are now 41 consultant pharmacist posts in England.  Few organisations have strategies for the appointment of consultant pharmacists and the main barriers appear to be financial. The largest numbers of consultant pharmacists work in paediatrics, antimicrobials and critical care, with the remainder spread over 18 different specialty areas. The majority work full time, and on average consultant pharmacists spend 50% of their time on clinical work. About one third of consultant pharmacists run clinics and two thirds of them are prescribers. A recent survey has shown that 60% of them have written chapters in books and the majority have given presentations at conferences. Mr Howard concluded that a research agenda and strategy for advanced practice need to be developed in order to make the best use of consultant pharmacists.
Effective pharmacy
“Sound science is the basis of effective pharmacy”, said Kevin Taylor (Head of the Department of Pharmaceutics and Professor of Clinical Pharmaceutics, The School of Pharmacy, London). Pharmacists have an unchallengeable body of knowledge, they have a unique perspective on medicines that is not shared with anyone else on the healthcare team, he continued. Clinical pharmaceutics can be described as the scientific and technological aspects of the design and manufacture of medicines linked to patient care.

Research in this field can be used to answer questions that are of immediate relevance to the clinical use of medicines and patient care. For example, when nebulised pentamidine isethionate was first used in the treatment of Pneumocystis carinii pneumonia (PCP) in patients with acquired immune deficiency syndrome (AIDS) there were a number of treatment failures. When the situation was investigated Professor Taylor’s team found that the injection was being used as a nebuliser solution and was at the limit of its solubility. During the process of nebulisation there was a rapid decrease in temperature and the drug precipitated, resulting in treatment failure. As a result of their investigations they were able to make recommendation about appropriate drug concentrations and nebuliser use. 

Another interesting case concerned the discovery of what appeared to be poppy seeds in the stomach aspirate from a baby – something that could have led to invasive procedures. Electron microscopy showed small, dark purple spheres that turned out to be degraded omeprazole pellets from MUPS (Multiple Unit Pellet System) tablets. Mass spectrometry confirmed the presence of undissolved omeprazole and degradation products. This suggested that there had been rapid degradation in stomach. 

The Children’s BNF recommends that the acid-labile pellets should be dispersed in sodium bicarbonate but this can be a problem for children in the paediatric intensive care unit, who may present with chronic alkalosis and so water had been used on this occasion. Once again, knowledge of pharmaceutics enables pharmacists to make a valuable contribution to the patient’s management, said Professor Taylor.

The PINCER trial
The PINCER trial was a cluster-randomised trial that compared the effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices. Rachel Howard (Lecturer in Pharmacy Practice, University of Reading), winner of the Pfizer Patient Safety Award, explained that the study had been prompted by the knowledge that the frequency of prescribing errors in UK primary care is 7.5% and that preventable drug-related morbidity accounts for 3.7% of hospital admissions. Initial work had identified NSAIDs, loop diuretics, anti-epileptics and antiplatelet agents as leading causes of preventable drug-related admissions and an education outreach model had been developed. The PINCER trial then tested the effectiveness of this intervention. A total of 72 practices were randomised. The intervention group received educational outreach, audit and feedback, together with assistance from a pharmacist. The control group received simple feedback comprising provision of audit results and evidence-based summaries. The results showed that at six months, participants in the intervention group were significantly less likely to have a prescribing problem or a monitoring problem. In addition, the improvement was largely maintained at 12 months. 

The researchers concluded that the scheme effectively harnesses the power of a multidisciplinary team to reduce hazardous medicines management in primary care. After further testing, it could be implemented more widely in primary care, said Dr Howard.

Social media
Social media are not unprofessional, hard to use or just for the young, according to Ryan Hamilton (President, British Pharmaceutical Students’ Assocation). They enable us to use web-based and mobile technologies to turn communication into interactive dialogue, he explained.

Facebook provides an easy way to keep in touch with colleagues around the world and need not be risky if privacy settings are used wisely. For organisations, it can be an effective way of communicating with members as social media sites tend to be visited more often than official websites.

Twitter offers one of the easiest ways of keeping up to date. Importantly, it can also be used to drive traffic to a website, he emphasised. YouTube offers a more interesting way of presenting some information than simple articles and organisations can exploit it for
joint working.

LinkedIn allows individuals to establish a professional presence online and acts as an online business card.  It can also be useful for organisations to bring members together.
Among the key reasons to use social media, Mr Hamilton highlighted the importance of knowledge sharing and rapid access to answers to queries together with the opportunity to promote the practice of clinical pharmacy as being particularly relevant to current needs

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