The hospital based pharmacy has a responsibility for safe use of medicines that goes beyond the walls of its department and ensuring steady, measurable improvements are made means that quality of care improves for the patient.
National Clinical Director
for Hospital Pharmacy
Department of Health
“High quality care for all” was the guiding principle for the NHS set out by Lord Darzi in his report of 2008.1 The report also included a definition of quality, setting out the three strands that together mean care is of high quality: patient experience, effectiveness of care and patient safety. I am going to focus on the third of these but it is worth considering the first two, especially as at times these have, perhaps, been neglected by pharmacy. Effectiveness of care is something pharmacists deal with every day in making choices around medicines – does the medicine give the outcomes we seek, what are the complications – but do we give sufficient thought to the effectiveness of the services we provide? Patient experience deals with issues of compassion, dignity, respect, the extent patients are involved in decision making around their care; does pharmacy address this in the way we supply, discuss and advise on medicines? Do we think about our own services from a patient’s perspective?
Then what of safety? Pharmacy has a strong record of being committed to safety in healthcare – standards for provision of aseptic products, design of supply services with checks on dispensing and increasing use of automation are just two examples. However, we know that harm still befalls patients from errors and mishaps with medicines while they are in hospital. In England, a key part of the Department of Health’s response to the need to ensure medicines are used more safely was to clarify the important role that senior pharmacists have in protecting patients. In the pharmacy white paper of 2008, chief pharmacists for hospitals (and other NHS organisations) were identified as the leaders responsible for ensuring that safe medicines use was embedded in patient care. This is both encouraging and daunting. Encouraging because it recognises the vital part the chief pharmacist has to play, daunting because it is a very challenging task requiring a multifaceted response. The responsibility goes beyond the walls of the pharmacy, it is not sufficient for the chief pharmacist to have safe supply and safe aseptic facilities – though of course these are a must. The responsibility includes the way medicines are used on the wards, and even beyond the confines of the hospital.
To respond to this all-encompassing need for safety, I believe there are three key “collaborations” – three sets of working relationships or aspects of partnership in delivering safer care. Firstly, perhaps quite obviously, with the pharmacy team. The chief pharmacist needs to convey the vision for safer use of medicines to the pharmacy team, developing with it a clear strategy to sustain and improve the quality of patient care. While the chief pharmacist may have certain areas of technical expertise, she or he needs to ensure the team includes those that can analyse and improve systems, review data and communicate key messages. The chief pharmacist also needs to delegate to the team and know how to coach and support to ensure good performance. Technical expertise is not sufficient, leadership skills are vital.
Secondly, having pharmacy leading on safe use of medicines does not mean only pharmacy is involved. Having the chief pharmacist as leader for medicines safety means they will develop strong working relationships with senior medical, nursing, general management staff and others. The whole healthcare team must be engaged, its expertise used to develop the best patient safety solutions. This senior multiprofessional approach should also be mirrored at the level of patient care, the pharmacist and pharmacy technician working alongside doctors and nurses to provide clinical pharmacy services that support safe prescribing and use of medicines.
The third collaboration is with peers. Networking with fellow chief pharmacists to solve problems together, to share good practice and for simple peer support is invaluable. There is often a shade of competition between such skilled and capable individuals but in the interests of patients and efficiency we really need to be able to import ideas from elsewhere rather than seek to reinvent something locally.
So, I have mentioned three collaborations necessary to deliver safer medicines use but of course there is a key partner not yet mentioned – the patient. Explaining the way medicines are to be used, clear labelling and so on are clearly important. We also need to consider how patients themselves can help us improve safety. Significant effort was made to ensure patients know the risks of MRSA – encouraging them to challenge clinical staff on hand washing. While it would not be right to pass the responsibility for safe administration of medicines to the patient, having them involved, and listening to their concerns, must surely be advantageous. One example is the checks on intrathecal chemotherapy. As part of a whole system to avoid inadvertent intrathecal administration of vinca alkaloids, guidance includes involving patients or carers in a check. This is of course to be done with sensitivity, but the guidance states: “As a minimum the member of staff administering the intrathecal chemotherapy should confirm the identity of the patient, explain the nature of the procedure, the drug that is to be administered and the route of administration.” Perhaps a similar system would deliver benefits in administration of insulin, for example, a medicine that is often on the list of most common errors.
Providing leadership, collaboration with others, engaging patients form the basic ingredients for safer medicines use, but on which other areas should pharmacists focus their attention? I do not believe there is one right answer to the question and, certainly, the risks vary between organisations. However, I will address one particular high-risk area – injectables. I have already mentioned maladministration of vinca alkaloids and the risks of insulin but mishaps and errors with injectables is known to be an area of significant morbidity and the cause of fatalities. In their report on the important contribution pharmacy can make to increase the safety of medicines use, the Royal Pharmaceutical Society of Great Britain summarised the evidence on the risks of injectables.5 They report an error rate of between 49% and 94% in administration of intravenous doses, based on their literature review. To describe this as troubling would be an understatement. While not every error causes harm, surely this is an area for pharmacy to take a strong leadership role and to seek improvement.
Provision of ready to administer injectables, either purchased or prepared in pharmacy, provides an important safety contribution. In the UK, the National Advisory Board for manufacturing and preparative services, have been funded by the Department of Health to support the rationalisation of injectable products in order to allow a move away from preparation in clinical areas to pharmacy-prepared, and to specials manufacturer production or even to licensed products.
It may be that collaboration across Europe would facilitate this process – for example standardisation on one particular soluble insulin for infusion, or on an agreed preparation of amiodarone infusion. In Wales and England, the National Patient Safety Agency issued its bulletin to address safety issues on injectables. This highlighted the important role of “purchasing for safety” – pharmacy leading the way to ensure products that are less likely to lead to errors are available. The report also set out the need for risk assessment, information support and audit, all supported by education. Safer use of injectables is not simply about product but also needs safe systems, ways of working, and for staff to be trained and alerted to the risks involved.
It may come fairly naturally to pharmacy to take a leadership role on safer use of injectables but what about less “product focused” issues? Transfer of care is an area where things can go wrong – with medicines or other aspects of the patient’s well-being. On discharge from hospital to the primary care team, or between hospitals, or from the mental health team to general practitioner, information on medicines needs to be shared. Changes in dose, medicines added to the regimen or medicines discontinued need to be explained to the health team taking over care. Information needs to be clear, explanatory, timely and accurate, and the recipient needs to be able to assimilate and use the information. Too often there have been problems, sometimes resulting in readmission or treatment failure. While of course medical teams are central in this activity, I believe pharmacy has a leadership role in identifying the problem and supporting or providing solutions. Part of the solution, as mentioned earlier, is to involve the patient. For example, in Darlington, a patient-held record made a real improvement in this area [detailed in reference 2].
I have chosen just two areas for attention, injectables and transfer of care, pharmacy leaders and their teams must address all aspects of safe medicines use. I believe pharmacy has a responsibility for safe use of medicines that does go beyond the walls of its departments. Having a clear vision and ensuring steady, measurable improvements are made, accepting this is a journey rather than a single step, will mean that quality of care improves for the patients we are here to protect.
1. Department of Health, High Quality Care For All – NHS Next Stage Review Final Report, TSO, London: 2008.
2. National Reporting and Learning Service, Safety in Doses – improving the use of medicines in the NHS, National Patient Safety Agency, London: 2009.
3. Department of Health, Pharmacy in England: Building on strengths – delivering the future, TSO, London: 2008.
4. Department of Health, HSC 2008/001 Updated national guidance on the safe administration of intrathecal chemotherapy, DH, London: 2008.
5. Vincent C, et al. RPSGB, London: 2009.
6. National Patient Safety Agency, Patient Safety Alert 20: Promoting safer use of injectable medicines, NPSA, London: 2007.