Medication Management How Nurse Prescribers Can Play Your Part in Delivering Safer, Better Care.

Damien Hirst Pharmacy(Installation, Cohen Gallery, New York, 1992)

Agenda 1. An overview of the Medication Safety Programme projects and areas for improvement 2. A presentation of the acute hospitals' Medication Prescription & Administration Record and how it is planned to support prescribers in their practice 3. Predicted Developments in Medication Reconciliation and Automation of Prescribing

But First The Political Landscape Why does this matter to a nurse prescriber?

Political Landscape Regulatory HIQA / PSI National Quality Standardsfor ResidentialCare for Older People 2009 and PSI Circular March 2010 HIQA National e-health Interoperability Standards for Ireland Consultation underway since 2012 Includes consultation about discharge prescription dataset

The Political Landscape Financial and Emergency Provision Legislation 2009-10 Erosion of pharmacy and GP payments Salary reductions per Haddington Road Health (Pricing and Supply of Medical Goods) Bill 2012 Reference pricing IMB lists of interchangeable medications Opportunities for automation Financial Crisis Hampering investment in technology Preventing recruitment Causing loss of experienced staff Damaging morale Pressure from Troika specifically on drug costs

The Three Buckets James Reason (2004) SELF CONTEXT TASK

The Three Buckets James Reason (2004) Custodial attention* Discretional energy * (extra mile) Experience Knowledge Fitness Self awareness *limited commodities eroded by bad stuff Preoccupation Inexperience Lack of knowledge Under the weather Fatigue Emotional state Life events Clear instructions Good briefing Good teamwork Available time Good rapport Able to question Good kit, etc Distractions Interruptions Change Harassment Hand-offs Authority gradient Poor workplace Forcing functions Standardization Alerts & reminders Multiple steps SELF CONTEXT TASK

Three Buckets Model meaning In any given situation, the probability of unsafe acts being committed is a function of the amount of bad stuff. in all three buckets. Full buckets do not guarantee an unsafe act, nor do empty ones ensure safety. We are talking probabilities not certainties. But with foreknowledge we can gauge these levels for any situation and act accordingly. Don t go there challenge assumptions, seek help.

Drivers for Medication Safety (IHI) 1. Reliable Medication Management Processes in residential care settings (acute hospitals, mental health facilities, nursing homes, hospices, maternity hospitals). 2. Good Co-ordination of Care at interfaces where care is transferred in the system. 3. Patient and family involvementin their own care.

Medication Safety Programme Top Priority Goals 2013 1. Standardisethe in-patient Medication Prescription & Administration Record (MPAR) in acute hospitals (including acute mental health facilities) to facilitate efficient care and minimise medication errors caused by documentation processes. 2. Implement medication reconciliationat transitions of carebetween hospitals, long-stay facilities and the community to reduce errors at handover of care. 3. Work towards introduction of technology to underpin safe, efficient work practices in medication management (electronic prescribing with decision support, automated dispensing systems, bar-code technology in drug administration, and seamless electronic communication of data throughout the patient journey).

Agenda 1. An overview of the Medication Safety Programme projects and areas for improvement 2. A presentation of the acute hospitals' Medication Prescription & Administration Record (MPAR) and how it is planned to support prescribers in their practice 3. Predicted Developments in Medication Reconciliation and Automation of Prescribing

Medication Safety Driver Diagram and Change Activities

Acute Hospitals MPAR Standardisation Main Goals 1. Prevent Hospital Acquired Thrombosis 2. Improve Use of Antimicrobials 3. Consider Allergies More Carefully 4. Eliminate a Cause of Missed Doses 5. Support Medication Reconciliation

HAT Prevention Why the Medication Chart? Provides a defined home for risk assessment Allows prescription of measures to flow from assessment easily Facilitates audit

Six Step VTE Risk Management 1. Classify the patient according to mobility 2. Assess risk factors for thrombosis 3. Assess risk factors for bleeding 4. Based on findings in previous steps decide whether or not to prescribe LMWH 5. Decide whether or not to prescribe antiembolism stockings 6. Reassess within 24 hrs or as clinical picture requires

Assessment of Knowledge of AMAU Doctors re VTE Risk Factors Staff tended to over-estimate their knowledge Only 1 in 3 had good knowledge Bassey, J. PRIMM Conference London Sep 2010

Problems Identified by Audit Failure to risk assess Failure to give thrombo-prophylaxis Delay in first dose of LMWH Unexplained gaps in LMWH prophylaxis Inappropriately low dose LMWH Delay in diagnosis & treatment of VTE Failure to prescribe according to risk assessment Some VTE events appear to be unpreventable Woodhouse P, Chair, Thrombosis Committee, Norwich & Norfolk University Hospitals

Structured Assessment Tool can address knowledge deficit Bassey, J. PRIMM Conference London Sep 2010

VTE Prophylaxis and Warfarin

Anti-embolism Stockings documentation

Antibiotics Section

SARI Guidelines 2009 Hospitals should consider introducing antimicrobial order forms, or designate a section of the prescription chart for antimicrobial prescribing, which includes a requirement for clinical indication and a required duration before order renewal. Order forms should distinguish between antimicrobials used for prophylaxis, and those used for active therapy. Consideration should be given to having separate order forms for peri-operative antimicrobial prophylaxis. Hospitals should introduce educational aids to guide prescribers at the point of prescribing. These may include clinical algorithms for the diagnosis of infection, or methods to standardise documentation of treatment decisions, such as infection stamps or stickers to be included in the clinical notes.

Compliance with SARI Guidelines in Acute Hospitals Charts obtained from 36 acute hospitals (October 2010) 15 had a surgical prophylaxis section (42%) 10 had a regular antibiotics section (27%) 7 had both prophylaxis and regular sections (19%) 2 had a separate chart for antibiotics (6%)

Feedback from Workshops (2011) Variable success with new antibiotic sections Some hospitals reported prescribers ignored new section and continue to write antibiotics with other drugs; Others report good compliance with use of section and completion of indication; Naas Hospital reported significant improvement in efficiency of antibiotic therapy following introduction of antibiotic section with reduced need for clinical pharmacists to contact prescribers with queries due to greater up-front clarity.

Surgical Prophylaxis

Regular Interval Antibiotics

Gentamicin, Vancomycin

Detail of Gentamicin Rx

Considering Allergies Failure to consider allergies when prescribing, dispensing or administering medication is the crucial contributory factor to this error type. A shift in practice is needed to ensure allergy status is considered at the critical point, i.e. immediately before prescribing, dispensing or administering any medication. A known allergen was prescribed and/or administered, despite the allergy being documented on the front of the Prescription and Administration Record in 63 of 66 reported incidents/near misses in an Irish teaching hospital. Source: CIS Newsletter, March 2011

Considering Allergies 50% of doctors and pharmacists and 35% of nurses stated they would not always check the patient s allergy status before prescribing/ administering/ endorsing a new antibiotic to/for a patient with no documentation in the allergies section on the Prescription and Administration Record In a small study in a Dublin teaching hospital 11/30 doctors (30%), and 27/38 nurses (70%) failed to correctly identify Tazocin from a list of medications as being contraindicated in penicillin allergy. In the same study 2/30 doctors (7%), 19/38 nurses failed to correctly identify diclofenac as contraindicated in aspirin allergy. Source: CIS Newsletter, March 2011

Allergic and non-allergic reactions

Mindfulness about Allergies

Making Medication Reconciliation Visible Documentation tool for pharmacists incorporated into chart to specify medication history prior to admission. To identify information sources To document pharmacy discharge prescription checks

Regular Prescription Section

Medication Reconciliation panel for admission & discharge

31 days administration Re-chart forcing function

Front cover

Height, weight, e-gfr

Chart rewrite, other chart checks

Visual Management: Patient Conditions affecting oral dosing

Standard order for medications during pre-operative fasting Source: Clinical guidelines: perioperative fasting in adults and children. Royal College of Nursing, 2005

Once only medications and infrequent depots

Pp 2-3 Communication

Dose omission codes

Variable dose heparin and other variable dose medication

Heparin Infusion protocol - Standard Loading Bolus

Heparin Infusion Protocol standardised infusion by syringe driver

Standardised Heparin dose adjustment based on APPTr results (non-weight based)

Variable dose design can accommodate multiple doses per day

Prescription design requires the prescriber to specify time to be given

As Required Prescriptions p22-24 (15 prescriptions)

Oxygen Therapy, IV Infusions

Oxygen Therapy

Back cover signature record

Signature record

HIQA 2011 Review of International eprescribing Initiatives Review included Denmark, Sweden, the Netherlands, USA, Australia, New Zealand, Northern Ireland, Scotland and England. Australia, New Zealand, Northern Ireland, Scotland and England were reviewed in detail. Aimed to understand the process and timelines which have been taken by other countries, identify the areas they have focused on, model / technical architecture implemented and understand the critical factors for success.

HIQA Review of International eprescribing Initiatives: Findings 1. All countries are focusing on eprescribing in the community, between general practitioners and community pharmacies rather than the secondary care setting. 2. Messaging standards, business process and drug reference catalogues are required and generally developed by technical standards bodies. 3. There is a dependence on the existence of identifiers for individuals, professionals and healthcare organisations (not all of which are in place in Ireland at present).

HIQA Review of International eprescribing Initiatives: Findings 4. Funding is centrally provided with payments to either/both general practitioners and community pharmacists on a onceoff or ongoing basis. 5. Electronic Prescriptions are exchanged via a messaging broker rather than direct between GP to pharmacy. 6. A phased implementation is generally undertaken with barcoded prescriptions existing in the initial implementation and continuing to be the authoritative prescription, followed in later phases with the implementation of electronic prescriptions and digital signatures which required legislative

Cloud Computing and Prescribing Patient G.P. Out of hours Doc 1st Consultant 2 nd Consultant Prescription Database Pharmacy H.S.E. 2 nd Pharmacy Nursing Homes A & E or Hospital With thanks to Mr Philip O Donnell

Other jurisdictions Northern Ireland 2 dimensional bar code Wales 2-dimensional printed bar code England Bar code with cloud database Estonia Paperless system for 98% of all prescriptions Australia considering mandating scanning of prescriptions pharmacies

Example of an Electronic Prescription (New Jersey, USA) With thanks to Mr Philip O Donnell

Prescriptions are issued by: Locums Out of Hours Doctors A & E Doctors NCHDs at discharge and in OPD Multiple Consultants in Rooms, Mental Health Hospitals, Acute Hospitals GMS and LTI With thanks to Mr Philip O Donnell

Transcription and Medication Reconciliation at Hand-over of Care The PCRS processed 17.508 million forms (prescriptions) for patients in the GMS, DP and LTI Schemes in 2009 With an average of three items per form, the total number of individual prescription items processed was 54.3 million. These claims were financial transactions between community pharmacy contractors and the PCRS, and they were handled electronically as might be expected for such a huge volume of claims.

Estimating the Burden of Transcription 2,800 GPs in Ireland in 1,300 practices. 775,000 GMS card holders were discharged from in-patient or day case care in public hospitals in 2010. It is estimated that at least 500,000 of these were given a prescription. These patients had to visit their GP in the days after discharge, the sole purpose of the visit being to have the GP transcribe their hospital prescription onto a GMS form. There were 1.6 million GMS patient episodes in hospital A&E departments & OPD Clinics in 2010. If we assume just one third of these episodes resulted in a prescription in the hospital, then 533,000 more people must go to a GP for a transcription.

Transcription and Medication Reconciliation at Hand-over of Care 6% of all prescribing done by GPs is transcribing for GMS patients - 3 million prescription items were transcribed in 2010. Between 150,000 to 710,000 prescription discrepancies are generated in this process each year Each of discrepancies is a latent error that may lead to patient harm.

Waste in the Prescription Value Stream Leading Edge Group, Adding Value to Irish Community Pharmacy June 2012

Avoidable Overheads Arising from Sub-Optimal Process Design Pharmacist Prescription Rework Estimated 4 hrs per week on rework 208hrs/year @ 37/hr = 7,696 1,700 pharmacies = 13. 083 million Technician Paperwork Estimated 7hrs technician time per week on HSE paperwork on average 364hrs/year @ 15/hr = 5,460 1,700 pharmacies = 9.282 million Leading Edge Group, Adding Value to Irish Community Pharmacy June 2012

Bar-coding to facilitate the transition to eprescribing an evolutionary model A patient visits their GP, who has compliant software i.e. software that has the ability to print an electronic unified prescription form. Following consultation, the GP decides to issue a prescription

GP Prescription System 1. GP enters the patient s information and prescription details onto their computer system. 2. Once complete, the software calls a new printer driver which prints a unified prescription form on a standard laser printer. 3. A paper prescription form (private, GMS, LTI etc.) with a 2D barcode is printed, signed by the GP and handed to the patient.

GP Prescription System 4. The unified prescription will be an A4 laser printed form, similar in style to the PCRS unified claim form. 5. The main difference will be the addition of a number of 2D barcodes down the right side. These barcodes encode the prescription information in electronic format. 6. The paper prescription form remains the legal entity

Bar-coded Prescription facilitates dispensing in community pharmacy Pharmacy System 7. The patient leaves the GP surgery and goes to a nearby pharmacy. It doesn t matter if the pharmacy has ETP compliant software or not the patient will still be able to obtain their prescribed medication.

Bar-coded Prescription facilitates dispensing 8. On arrival at the pharmacy, the patient hands over the unified prescription form to the pharmacist. 9. Rather than having to re-type the details of the prescription into their system, the pharmacist simply scans the barcode using a barcode scanner. 10. The prescription details are retrieved from the barcode and downloaded directly onto the pharmacist s system.

Bar-coded Prescription facilitates dispensing 11. The pharmacist selects the medication appropriate to fulfil the prescription, prints a medication label and prepares the medication ready to give to the patient. 12. The medication is checked and then dispensed to the patient. 13. The barcode information scanned from the prescription is added to the prescription record on the pharmacy computer system.

Bar-coded Prescription facilitates national data collection for prescribing as well as dispensing 14. At the end of the month, the pharmacy transfer their claims electronically to the Primary Care Reimbursement Service (PCRS). 15. For those claims where the new unified prescription form was scanned, the prescribed data will be appended to the current dispensed data. PCRS then processes the claim and reimburses the pharmacy.

Benefits of Having National Prescription Data Permits direct analysis of GP prescribing habits as well as pharmacy dispensing records Reduces risk of fraud/increases transparency The Netherlands* developed a set of 42 indicators for community pharmacy care. The set contains indicators on patient counselling (6), clinical risk management (10), compounding (7) & dispensing (3), monitoring of medication use (11) quality management (5). It is expected that this will have a positive impact on quality and safety of community pharmacy care. * De Bie et al BMJ Qual Saf 2011;20:666-671 doi:10.1136/bmjqs.2010.045237

Conclusions on technology 1. Reduces costs and risks for everyone HSE, GPs, nurse prescribers, community pharmacies, patients. 2. Bar-code technology for dispensing will reduce error and increase cost-efficiency. 3. Bar code technology for prescribing will mean safer care, greater prescribing efficiency, dramatically reduced transcription error 4. It will eliminate a hidden factory of re-work in GP practices and community pharmacies 5. Bar codes printed on paper prescriptions can be a transitional step towards a system that is safer for patients and provide a quick win 6. Vendors are already capable of providing this -it is a matter of us enabling it via policy change on prescription forms.

Damien Hirst Pharmacy(Installation, Cohen Gallery, New York, 1992)