Reducing medicines waste in Care Settings.

Reducing medicines waste in Care Settings. Good practice Guidance Recommendations for care home staff, prescribers and pharmacists working with care homes. This good practice guidance has been developed by: The Medicines Optimisation Team at The Isle of Wight Clinical Commissioning Group. June 2017

Background: Unwanted medicines returned to Pharmacy cannot be re-used. Nationally the NHS waste figure is estimated at three hundred million pounds. It is estimated nationally that approximately 10% of all prescribed medicines are not used. In 2015/16 the total spent on prescribed medicines on the Isle of Wight was 29m, meaning 2.9m was potentially wasted. On the Isle of Wight, around 1m worth of medicines are returned to pharmacies for disposal each year. This is an astonishing figure! This could help to fund 34 more District Nurses or 180 more Hip Replacement surgeries. It is recognised that medicines waste occurs throughout the whole economy. It is also widely reported by those involved with medication in a care home, and that they are keen to reduce wastage. Care home residents are often on numerous medicines and may administer their own medicines, but more commonly staff will assist with their medicines; for these reasons care homes have a key role in helping to reduce medicines waste. Having good procedures for ordering, storage and administration of medicines can help to reduce medicines waste. This guidance promotes best practice for the procurement of medication in care settings. NICE guidelines (SC1) Recommendations for ordering medicines, Care home providers must ensure that medicines prescribed for a resident are not used by other residents Care home providers should ensure that care home staff has protected time to order medicines and check medicines delivered to the home. Care home providers should ensure that at least two members of the care home staff have the training and skills to order medicines, although ordering can be done by one member of staff. Care home providers should retain responsibility for ordering medicines from the G.P practice and should not delegate this to the supplying pharmacy. Care home providers should ensure that records are kept of medicines ordered. Medicines delivered to the care home should be checked against a record of the order to make sure that all medicines ordered have been prescribed and supplied correctly.

Key Points: Ordering Ensure the setting has a robust monthly medication ordering system in place, and a dedicated person/s to carry out the process. Check quantities/stock levels of all medicines before re-ordering. Medicines supplied by the community pharmacy cannot be re-used so only order what is needed. Ask the G.P practice to send residents/service users prescriptions/dispensing tokens back to the care setting to be checked for any discrepancies before dispensing It is too late once an unwanted item reaches the setting. If prescriptions for items that are not required or missing prescription items are discovered then this should be raised with the G.P practice, not the pharmacy. Ask the community pharmacy/dispensing practice to remove discontinued items from the MAR chart. This helps prevent discontinued medicines being ordered/supplied in error (this should be carried out monthly). Communication is key Work with all those involved in the ordering and supply of medicines to ensure good lines of communication and timely supplies. Get to know the people involved at each point of ordering, prescribing, generating prescriptions and dispensing. Only order when required medicine s (prn s) when stock levels get low, this probably won t be every Month. Key points: Administration If medication/preparation is still being prescribed for a resident and it is in date Do Not dispose of any leftover stock at the end of the month, carry it forward(make a note on the MAR chart) and use it the following month.* Ensure correct amounts of creams and ointments are used and only change dressings as per instructions. ** Meet regularly with the community pharmacy and G.P practice to ensure clarity of the ordering process If residents continually refuse to take certain medicines discuss with the prescriber before reordering. The G.P needs to be contacted after two missed doses ***as this may need a review by the G.P. Some medicines are much more crucial than others; if you are unsure please contact your local pharmacy for advice. Ensure the residents medications are reviewed regularly by the G.P and/or Medicines Optimisation Team. This is usually annually, but can be more frequent. Remember if you don t need it don t order it! *This does not apply to part used Monitored Dosage Systems. These should be disposed of at the end of each month. **This is likely to vary from product to product. *** See below list of medicines to notify G.P of refusal

Best Practice Advice for reducing medicines waste in care homes: Ordering process There should be a monthly, systematic ordering protocol for medicines(28 day cycle) and ordering processes should ensure previous usage of medicines is reviewed and a check of what medicines residents already have in stock before re-ordering. Once the prescriptions have been generated by the G.P practice they should be sent back to the home to be checked for any discrepancies items missing that are required or items on the prescriptions that are not required for this month s cycle-this should be discussed with the appropriate person at the G.P practice. The prescriptions should then be sent back to the Pharmacy/dispensing practice to be dispensed. The Medicine Administration Record (MAR) chart should be used to re-order medicines, ask the community pharmacist to remove discontinued medicines from the MAR chart regularly. If the repeat side of a resident s prescriptions are used to order medicines ask the Prescription clerk at the G.P practice to remove any discontinued medicines. This helps to prevent discontinued medicines from being ordered in error. If however some discontinued items remain ensure to draw a line through the item and put a Zero in the quantity box. If a resident s medicines run out at different times during the month speak to the G.P, Prescription clerk or Pharmacy Technician about getting their medicines synchronised so all medicines run out at the same time in the ordering cycle. This may mean having a smaller quantity one month for some medicines so they all run out on the same day. Meetings between the G.P practice, Pharmacy and Care home are beneficial to ensure the medicines ordering process is understood by all involved and can help address issues and concerns as they arise. New members of the care home team and G.P practice involved in the ordering process should introduce themselves to each other. A named person at each stage of the process helps to maintain good levels of communication. Medicines must always be rotated on arrival so that older medicines are used first. Any medicine that the resident is no longer taking should be crossed off the MAR chart with a record of the details, ie: reason, date and GP name etc. The G.P and community pharmacy records should be updated to reflect this, therefore the communication around this needs to be documented in the ordering policy/medicines policy within the home. Disposal of medicines Do NOT discard all unused medicines at the end of each month. For example some creams and inhalers do not need to be ordered monthly, they can be used up until their expiry date or for a certain length of time after opening according to the manufacturer. Ensure dates are added to items once opened. Most preparations are stable until their expiry date- If you have any queries regarding how long you can use a product once opened contact your local Pharmacy or CCG Pharmacist/Technician for advice.

Disposal of medicines continued Keep supplies to a minimum to prevent stocks going out of date. A resident s medicine may be stopped or changed by the G.P at any point, and then any stock remaining becomes waste. If a medicine has been ordered that isn t needed, ensure the community pharmacy is contacted as soon as possible to prevent the supply leaving the pharmacy. If a medicine that isn t required leave the pharmacy/is delivered to the home the Pharmacist cannot re-use the medicine and it would be destroyed, therefore it is essential that only medicines needed are ordered. Do NOT discard all external preparations, such as creams and ointments a month after opening. Most preparations are stable until their expiry date If you have any queries regarding how long you can use a product once opened contact your local pharmacy or CCG Pharmacist/Technician for advice. (see numbers below) (See The Isle of Wight CCG s Good Practice Guidance on the Expiry Dates and Storage of Medicines in Care Homes for further information and Table of suggested Expiry Dates of Products from Date of opening on the next page for guidance.) Quantities of Medicines: Check what medicines are required before they are ordered Do Not automatically order everything. Do not order when required (PRN) medicines each month if there is still an adequate supply available in the home. If a resident is using a PRN medicine regularly, discuss this with the G.P at the next review as it may be appropriate to alter the medication or dose. PRN medicines should be dispensed in their original packs wherever possible to give their longest shelf life. Discuss with the prescription clerk if quantities of medicines received are inappropriate. This can be altered if necessary. If quantities are too high this can lead to waste, if quantities are too low the home may need to order more frequently. The use of seven day prescriptions is only recommended when there is a clinical need for the patient, i.e, A resident is at risk of overdose or misuse if more than seven days medication is supplied. Patients requiring seven day prescriptions will have had a Disability Discrimination Act Reducing Medicines Waste examples One care home was receiving 92g tubes of Cavilon for all 17 residents and throwing them away at the end of each cycle. After discussions with the staff we agreed that the G.P practice would supply 28g tubes which would reduce wastage. This saved 915 for the practice in one year. One residential care home was discarding all resident s medications at the end of every month regardless of expiry dates, these were returned to their local pharmacy for destruction and the pharmacy estimated the waste to be approximately 7000 per year!

Medicines optimisation - Ensure residents are getting the best from their medicines: Medication should be reviewed regularly by the G.P or Pharmacist. If a Resident has not had their medicines reviewed recently or there is a concern about a resident s medication this should be discussed with their G.P If there are medicines that a resident is refusing regularly discussions need to be had with their G.P as it could need a review, or possibly need to be stopped. Formulation Recommended expiry date Tablets and capsules packed in an MDS Tablets and capsules - in original bluster/foil pack eg, prn medicines 2 months (unless stated otherwise by pharmacy) Manufacturers expiry date Tablets and capsules - loose ie, dispensed into a bottle by pharmacy recommendation whichever is shorter. Liquids (internal) recommendation whichever is shorter. Liquids (external) Emollients in tubes or with a pump dispenser. Emollients in tubs with a lid recommendation whichever is shorter. recommendation whichever is shorter. For unopened creams follow the manufacturers recommendation. 3 months from date of opening or manufacturers recommendation whichever is shorter. For unopened creams follow the manufacturers recommendation. Medicated creams/ointments eg. Clotrimazole/hydrocortisone Suppositories/Pessaries/Rectal tubes/patches Inhalers Ear/Nose drops and sprays Eye drops One month from opening or manufacturers recommendation whichever is shorter. For unopened creams follow the manufacturers expiry date. Manufacturers expiry date Manufacturers expiry date Discard Three months after opening unless manufacturer advises otherwise. Discard One month after opening unless otherwise stated by the manufacturer. NB. Ask your supplying pharmacy to add batch numbers and expiry dates to all products that are not dispensed in the original container.

Quantities of medicines Oral nutritional Supplements (ONS), Continence products and dressings. Does your resident really need a nutritional supplement? Residents requiring Oral Nutritional Supplements in place of a meal should have their supplements provided by the care home; If however the resident has increased calorific requirements then a prescription could be issued by the G.P for a powdered supplement i.e.; complan or aymes shake. Pay particular attention to quantities of nutritional supplements, particularly for new residents or residents newly initiated on these products. It is recommended that G.P s only prescribe a one week supply of ONS for a new resident and checks for preference of flavours before issuing. All Oral Nutritional Supplements should be reviewed regularly, with an up to date BMI recorded. Continence products stocks should be kept to a minimum and stocks of dressings should be kept for individual residents only. List of medicines to notify G.P if residents are refusing Blood pressure medicines. E.g. amlodipine Anti-Epilepsy medicines. E.g. Sodium valproate Anti-psychotics. E.g. Aripiprazole Anti-diabetic medicines. E.g. Metformin Warfarin or NOAC s Insulin injections Parkinson s disease medicines If you require any further information or have any questions related to this Good Practice Guidance please contact: Hayley Jeneson Locality Specialist Medicines Optimisation Pharmacy Technician Isle of Wight Clinical Commissioning Group CCG HQ Building A The APEX St Cross Business Park Newport Isle of Wight PO30 5XW Telephone 01983 55(4769) Remember if you don t need it don t order it!