Report to the Trust Board

Transcription

1 Report to the Trust Board Southport & Ormskirk Hospital NHS Trust Date of Board Meeting 26 January 2011 AGENDA ITEM: 7c Title of Report EXECUTIVE SUMMARY of the REPORT (please outline the purpose of this report and the key issues for consideration) Prepared by (author of report) Presented by (Executive Director) ACTIONS REQUIRED (to note, endorse, approve recommendations etc) D&T Annual Report The Trust Drugs and Therapeutics Committee s business included 11 monthly meetings during the year with no meeting scheduled for August Items considered by the Committee included the managed entry of new medicines into the Trust in liaison with the local Area Medicines Management Committee; identifying risks associated with medicines use within the Trust and promoting improvements in patient safety and commissioning several audits in relevant areas, especially those required in relation to NPSA, NICE and other governance bodies. Minutes of all meetings and other papers are available on request Adrian Brown : Chief Pharmacist / Deputy Chair DTC Geraldine Boocock Medical Director Members of the Committee are asked to note the content of the Report circulated with the Agenda and raise any issues at the meeting. Various actions have been taken by the Committee in year as indicated in the Annual Report. Some issues have been escalated to the Risk Management Committee where appropriate. Board members are asked to note and approve the report Which Strategic Objective(s) are supported by this paper Is this on the Trust s Risk Register? If yes, please provide details Are they any financial implications? If yes, please provide details 1,2 & 5 Risk register entries in connection with this report: NPSA alert partial non compliance. Drs prescribing errors. No Previous Meetings If applicable, please insert the date this paper was presented to the relevant Committee/Meeting:- Finance & Performance Committee Audit Committee Risk Committee 15 December 2010 Quality Committee Senior Executive Management Team Other (please state) 0

2 1. EXECUTIVE SUMMARY Southport and Ormskirk NHS Trust Drugs and Therapeutics Committee Annual Report The Trust Drugs and Therapeutics Committee s business included 11 monthly meetings during the year with no meeting scheduled for August Items considered by the Committee included the managed entry of new medicines into the Trust in liaison with the local Area Medicines Management Committee; identifying risks associated with medicines use within the Trust and promoting improvements in patient safety and commissioning several audits in relevant areas, especially those required in relation to NPSA, NICE and other governance bodies. Minutes of all meetings and other papers are available on request. 2. NEW MEDICINES The following medicines were approved for use within the Committee, after having first been considered by the Area Medicines Management Committee: 2.2 Sodium Hyaluronidate Intra-articular injection ( Synvisc and Durolane) 2.3 Insulin Glulisine, a long-acting insulin analogue 2.4 Tadalafil, a phosphodiesterase inhibitor for erectile dysfunction, already approved on the hospital formulary was approved at a lower dose formulation for daily use 2.5 Suprasorb C. This dressing was proposed to replace the use of Modulator dressing over which it had some advantages. 2.6 Dabigatran. This anticoagulant was agreed to replace Rivaroxiban in elective orthopaedic surgery as the latter had resulted in an unacceptable incidence of postoperative bleeding following hip and knee surgery. 2.7 Oral Tramadol as an option for analgesia in A&E patients The following product was rejected by the Committee: 2.8 BD Normal Saline syringes. This was declined on cost-effectiveness grounds. 3. CHAIRMAN S ACTION The following products were approved for use by the chairman or deputy in individual patients: Altretinoin for a patient with severe refractory eczema (Sept) Aliskiren for a patient with hypertension resistant to conventional therapy ( Sept) Tafluprost eye drops for a patient with open angle glaucoma refractory to first line treatment (Oct) Indomethacin for an patent with heterotrophic ossification ( Jan) Riluzole for a patient with motor neurone disease (Feb) 1

3 4. RISK AND PATIENT SAFETY 4.1 NPSA Alerts Midazolam (NPSA/2008/RRR011) final actions were implemented to ensure compliance. These included removal of high strength injection from stock in all areas & a formal process for monitoring flumazenil use. (Sept) Bowel Cleansing Agents (NPSA/RRR/12): Significant requirements for compliance included the provision of medication and information at a face to face consultation with a heather care professional. The Trust was non-compliant with this alert in that BCAs were being posted out to patients directly referred by their GP for colonoscopy. Meetings took place throughout the year with key stakeholders aimed at resolving this issue. Compliance with this Alert was required by September 2009 but significant issues remained unresolved throughout the year. The Trust s non-compliance status was entered on to the Trust Risk Register as High Risk. (Sept) Omitted and Delayed Doses. (NPSA/2010/RRR009) Prior to this alert being issued, the Trust had already carried out an audit which identified that several wards had a high rate of prescribed doses not being administered. In some wards the figure had approached 25%. An Organisational Gap Analysis was carried out in year and the Trust continues to work towards compliance with recommendations within the Alert by the due date Safer Lithium Therapy (NPSA/2009/PSA 0005) The Trust was working with the Mental Health Trusts to ensure compliance with this alert by the due date (December 2010) Vaccines (NPSA/2010/RRR008) Although comparatively few areas in the Trust store vaccines, an audit in January on all wards and departments documented some deficiencies in refrigeration facilities (many existing ward fridges did not have minimum and maximum thermometers) and there was often inadequate documentation of temperature monitoring. An action plan was developed to address these problems. 4.2 Medication Incidents & Medication Safety Bulletins Several serious incidents had been reported to the Committee during the year. Potentially life-threatening incidents are listed here Penicillins being prescribed to Penicillin-Allergic Patients There were several incidents reported where penicillins had been prescribed to penicillinallergic patients. The agents concerned were often combination products, (e.g. Coamoxiclav and Piperacillin/Tazobactam) where it may not have been apparent to prescribers that the product contained a penicillin component. Most instances were identified by pharmacists and corrected before the drug had been administered to patients, but on some occasions patients did receive the product. A medication safety bulletin was issued to all prescribers drawing attention to the incidents which had occurred. Posters and awareness raising sessions with medical and nursing staff were also undertaken by the pharmacy and microbiology departments. This issue was escalated to the Risk Management Committee for information. 2

4 4.2.2 Other Serious Incidents There had been an incident where Morphine Sulphate s/r had been prescribed at a dose of 100mg twice a day in error for 10mg twice a day. This error had been due to incorrect medication information being available on admission, and again prompted a medication safety bulletin. Methotrexate had been prescribed daily, in error instead of weekly. Again this resulted in a Medication Safety Bulletin being issued to all prescribers Medication Error Matrix A Trust medication error matrix for nurses was introduced throughout the Trust based on a format used in other Local Trusts (April) 4.4 Other Risk and Safety Issues Junior Doctor Prescribing Errors In collaboration with several other Trusts from the North West, a research project was undertaken to identify and quantify prescribing errors at ward level. A series of monthly point prevalence studies was carried out by pharmacists and the data collated by the investigation team at Manchester University. The mean prescribing error rate for the Trust was 13.4%, which compared with a mean error rate of 8.9% in the cohort as a whole. This was escalated to the Risk Management Committee and a proposed action plan developed Pharmacy Staffing Issues. It was noted at several meetings through the year that pharmacy staffing levels had given cause for concern, and had resulted in several incident forms being submitted where clinical services to individual wards had been curtailed due to inadequate staffing. The issue had been raised with the Chief Executive, the Medical Director and other officers who had agreed a series of proposals with the Chief Pharmacist to address the situation. As stated there was a specific problem with achieving compliance with NICE/NPSA Clinical Guideline (PSG 001) Technical solutions to medicine reconciliation in adults admitted to hospitals The Committee continued to monitor the situation throughout the year Off-Label administration of Sodium Tetradecyl Sulphate Injection ( Vibrovein ) into Oral Palate ( Snoreplasty ) It came to the Committee s notice that there had been established use of the above product within the Trust as a treatment for refractory snoring. However, the use of the product in this way was outside the product license (off-label) and the procedure had not been sanctioned with the Drugs and Therapeutics Committee. The Committee s decision was to refer the matter to the Interventions Procedures and New Equipment and Techniques Committee (IP & NET) for ratification. 3

5 5. ANTIMICROBIAL PRESCRIBING Major issues were as follows: As stated above there had been several instances of penicillin products prescribed to penicillin-sensitive patients in year. A full time antimicrobial pharmacist (Christopher Little) was appointed to the antimicrobial pharmacist vacant post in September 2009 and joined the Committee. The Trust Antimicrobial Guidelines were reviewed and issued to all prescribers during the year. Two point prevalence audits of antimicrobial prescribing were carried out in-year ( see audits below) Data for restricted agents had been collated using the indicator: Defined Daily Doses (DDDs per 1000 Bed days) and used to identify Trends. Ciprofloxacin was withdrawn from stock from all wards and departments in an attempt to control its use. A 3 rd Consultant Medical Microbiologist was appointed in March 2010 to facilitate regular antimicrobial and Clostridium difficile management ward rounds. 6 PATIENT GROUP DIRECTIONS (PGDs) The Trust Policy on Patient Group Directions was reviewed and updated in year. Several PGDs were reviewed and approved by the Committee in year. Details of all PGDs presently in use are listed on the Trust Intranet. 7. AUDITS Several audits were commissioned by the Committee and undertaken by the Pharmacy Department in year. Details of all audits are available on request, but important ones included: 7.1 Oral and Enteral Liquid Medicines (NPSA/2007/19) Although the Trust had previously declared compliance with the requirements of this alert an audit was presented which identified some deficiencies in practice. Some wards did not have stocks of oral/enteral syringes. The results of this audit prompted additional measures to raise awareness of the Alert s recommendations (Posters, briefing sessions for ward staff etc). 7.2 Two point Prevalence Audits of Antimicrobial Prescribing These demonstrated 88% (Nov 2009) and 97% (Feb 2010) compliance with antimicrobial guidelines. 4

6 7.3 Pharmacists Interventions to Improve Prescribing on all wards 388 interventions by pharmacists to improve prescribing had been documented within the 2 week audit period, of which 153 were classed as either of major or life-threatening significance. In 96% of cases the pharmacists advice was accepted and the prescription altered accordingly. 7.4 Evaluation of Prescribing Accuracy A point-prevalence study was carried out on one day in in-patient, out-patient and discharge (TTO) prescriptions. The results demonstrated that out of a total of 915 items prescribed, 123 (13.4%) contained an error. Of these errors 0.8% were described as potentially life-threatening; 3.3% were serious and 31.7% were significant. The majority of prescriptions were written in accordance with the Trust Medicines Management Policy. 8. FINANCIAL MONITORING 8.1 Medicines Spend against Budget Tracking of drug spend against budget was included as a standing agenda item to monitor trends. More detailed expenditure for individual specialties was considered when appropriate. At year end the total drug spend within the Trust was under-spent at 5,968,673 against a drugs budget of 6,156, Initiatives for Cost Improvement Programmes (CIP). Clinical Specialist pharmacists were asked by the Committee to liaise with medical and nursing staff in their speciality to identify any areas of cost-efficiencies which might be achievable. Two initiatives are listed here Generic Clopidogrel The release of a generic version of clopidogrel in-year resulted in the Trust saving around 50K. The licensed indications for the generic version were slightly more restricted than those for the branded version, but cardiologists and others had been persuaded to adopt its use for all indications Rationalisation of Seretide to Symbicort Choosing to use Symbicort as a first-choice combination inhaler (long-acting beta-agonist plus steroid) instead of Seretide would result in a potential cost saving of 10K. Although this proposed change was agreed with the relevant consultants the actual savings were somewhat lower in that some patients did not tolerate Symbicort (a dry-powder inhaler) and preferred Seretide (a metered-dose inhaler). 9. ACCOUNTABLE OFFICER ISSUES / CONTROLLED DRUGS Issues in relation to controlled drugs had been collated on a regular basis for the Local Intelligence Network by the Accountable Officer (Chief Pharmacist) and these were copied to the Committee for information. 5

7 10. OTHER ISSUES NICE guidance on Adherence to Medicines (CG76) Released in January 2009 the document contained many recommendations on best practice for prescribers in terms of optimising the chances of patients adhering to their treatment. It was very difficult to assess whether or not individual prescribers were compliant with the recommendations and if so how to produce evidence of compliance. (Sept) It was decided to audit prescribers awareness of the recommendations within the document and gain an insight into current prescribing practice Introduction of New In-Patient prescription Chart After an earlier audit of missed medication doses the Committee decided to commission the design of a new in-patient prescription chart. A working group designed the new chart which was piloted in September and rolled out throughout all adult wards within the Trust over the following months Terms of Reference of the Committee. The membership and terms of reference for the Committee were reviewed and agreed in year. The terms of Reference are attached to the report as an appendix (Attached). Adrian Brown Chief Pharmacist & Deputy Chair Drugs and Therapeutics Committee. November

8 Appendix : Southport and Ormskirk Hospital Drug and Therapeutics Committee Terms of Reference Membership Chair nominated Consultant Chief Pharmacist, Deputy Chair Deputy Chief Pharmacist Interface Pharmacists Medicines Information and Formulary Pharmacist Clinical Pharmacy Services Manager Medical Director(s) Consultant Anaesthetics Consultant Emergency Medicine Consultant General Surgery Consultant Haematology Consultant Medical Microbiology Consultants - Medicine (2) Consultant Obstetrics and Gynaecology Consultant Ophthalmology Consultant Orthopaedics Consultant Paediatrics Consultant Palliative Care Consultant Spinal Consultant Urology Consultant Accident & Emergency Junior Doctor Representative Heads of Nursing Specialist Services Consultant Nurse (Lead Non-Medical Prescribing) Other Consultants and Specialist Nurses in Attendance Clinical Risk Coordinator Lead Accountant D.G.M. as appropriate Copies of minutes to be sent to all members and to Associate Medical Directors Purpose and Duties To direct the work of Medicines Management. This encompasses all systems, policies and procedures designed to ensure the safe, secure and cost-effective use of medicines across the Trust. This includes: appropriate and affordable prescribing practice safe and secure supply, storage and administration of medicines efficient purchase and distribution systems for medicines development of services to improve the clinical use of medicines Aim To positively influence the quality, cost-effectiveness and safety of medicines use across Southport & Ormskirk Hospital, the surrounding PCT s and the local health economy. Objectives 1. To develop strategic and operational policies to improve the management of medicines within Southport and Ormskirk Hospital, and across the interface. 7

9 2. To ensure policies and procedures promote the safe and secure handling of medicines in line with the Duthie Report (under revision), NHS Controls Assurance Standards and legal and ethical requirements. 3. To give appropriate support to all relevant clinicians on the safe, effective and evidence based use of medicines. 4. To develop measures/indicators for monitoring the management of medicines. These should cover: safe and cost-effective prescribing clinical and financial risk management (e.g. budgets, adverse incidents, audit, education and training) impact assessment of changes in prescribing in cooperation with divisional management and cabinet as necessary 5. To ensure that all nationally and locally agreed guidelines 9NICE, NPSA, NSF s etc where related to medicines) are reviewed and audited. 6. To develop coherent policies and procedures for the introduction of new technologies in conjunction with the Area Medicines Management Committee to provide a Health Economy Approach to Medicines Management. Representatives from the Trust s Drugs & Therapeutics Committee will form part of the membership of the Area Medicines Management Committee, namely:- Chair, Drugs & Therapeutics Committee Trust Consultant Representative Chief Pharmacist Interface Pharmacist Trust Accountant 7. To oversee the work of the Patient Group Directions (PGD) working group. 8. To develop and maintain an agreed evidence based formulary, in conjunction with the Area Medicines Management Committee and to monitor compliance with the formulary via audit and through purchasing. 9. To manage the use of sample medicines and unlicensed drugs across the Trust. 10. To ensure that the use of drugs in clinical trials only occurs after ethical approval and completion of Trust requirements. 11. To review and approve Care Pathways and Protocols. 12. To contribute to continued education and training of all staff as appropriate. Frequency of Meeting The committee will meet on the third Tuesday of each month. Dates will be set in advance for each year. Standard Agenda Items Area Medicines Management Committee Update Formulary development Finance reports Newsletter for approval Patient Group Directions Monthly Review of Drug Incidents Chairmans action Antimicrobial prescribing review Items for Risk Committee 8

10 Links with other Committees/Organisations 1. To feed into North Sefton and West Lancashire Area Medicines Management Committee. 2. To maintain links with the local PCT s through the Interface Pharmacists, and advise on the development of joint initiatives such as formularies, and patient pack dispensing. 2. Evidence Based Practice Committee. Accountability and Reporting The DTC is accountable to the Trust Board via the Risk Management Committee. The Committee will report to the Risk Management Committee via the members. In addition, Minutes are reviewed by the Trust Quality Committee. Review The Drug and Therapeutics Committee will review these terms of reference annually. Reviewed by the DTC: Date 17 th March 2009 Signed.. Name Position Next Review Date 22 nd March