Development of medicines management in hospitals
Medication errors alone cost the National Health Service
£500m a year in additional days spent in hospital, said Michael Pollard,
chief pharmacist and clinical director, Wrexham Maelor Hospital, during
the hospital pharmacy programme, on 8 October. A study published in the
British Medical Journal earlier this year had shown that 10.8 per
cent of patients on a medical ward experienced an adverse event due to
medication and that of these 46 per cent were preventable. “Clearly there
is a problem,” he said.
Errors can occur at every point in the patient’s
journey through hospital, from the time of admission to the time of discharge.
Mr Pollard went on to describe the action he had taken in his hospital
to try to reduce errors. One of the main things was to ensure that a drug
history is always taken by a member of the pharmacy staff or a doctor.
Patients are encouraged to bring their own medication into hospital and
keep it with them. Any additional medication prescribed in hospital is
provided in patient packs and stored in a bedside cabinet. Medication
is administered from bedside lockers rather than drug trolleys, and self-administration
encouraged where possible.
Discharge is carefully structured with doctors indicating
changes to medication in the notes and pharmacy staff providing follow
up. Above all, it is essential to ensure that patients have full knowledge
of their medication, why they are taking it, its appearance and side effects.
Patients themselves can provide major safety checks in most hospitals
and clinics if properly informed and educated to do so, he concluded.
Peter Sharott, pharmaceutical adviser (secondary
care) NHSE, London, described the review of medicines management currently
taking place in hospitals. Concern about the 12 per cent annual growth
rate in medicines expenditure (highlighted by the NHS efficiency task
force in 1999) led to the decision to develop a performance management
framework as a means of investigating the clinical and cost-effective
use of medicines in hospital trusts.
Mr Sharott went on to say that as part of this work,
a questionnaire had been sent to trusts to investigate the current situation
in relation to medicines management. Results from the questionnaire show
that senior managers (not just in pharmacy) are not particularly aware
of medicines management issues, and the vast majority of trusts have no
strategy for it. This is important for pharmacy in that pharmacy services
form part of the whole structure and medicines management issues have
to be addressed as such. Issues relating to drug budget setting and procurement
of medicines are being reasonably well addressed, although there is room
for improvement. Clinical pharmacy services account for just 20 per cent
of the total cost of services to patients and the aim should be to increase
this, he said.
All trusts responding to the questionnaire have
drug and therapeutics committees and 95 per cent have formularies. When
asked about managed entry of new drugs, most said this is the responsibility
of drug and therapeutics committees, although some trusts have separate
new drugs committees. Introduction of new drugs is of interest not only
in secondary care, but also increasingly in primary care, which wants
its say in which new drugs are used.
Responses to questions about primary/secondary
care interface issues indicated that many trusts think they are performing
well on this, but this is only because of a large number of pilot studies,
Mr Sharott said. The pressure on hospitals to deliver services such as
using patients’ own drugs and self-medication schemes is enormous, but
this will take considerable resources, he concluded.
Pharmaceutical care research
Sarah Tulip, research pharmacist, North Durham Health
Care NHS Trust, highlighted inconsistencies in the delivery of pharmaceutical
care in hospitals. Practice is poorly developed, with no universally accepted
model of pharmaceutical care in hospitals, and this is reflected in a
paucity of sound research, she said.
She went on to describe some of her own research
in which she has found that pharmacists based on wards are more likely
to influence patient care than those who just visit wards in the traditional
way. Subjective responses by doctors suggest that they find it helpful
having pharmacists on wards at the time of prescribing, that it reduces
the risks associated with drug therapy. They want pharmacists to write
discharge prescriptions. Positive responses were also obtained from patients,
with many commenting that no-one before had ever explained to them the
purpose of their medication.
Ms Tulip explained some of the problems of researching
pharmaceutical care. The complex nature of pharmaceutical care made it
difficult to evaluate and researchers often tried to reduce the complexity
by focusing on discrete segments of care. However, it was then difficult
to relate pharmaceutical care interventions to outcomes.
For future work it will be essential to develop
a fully standardised definition for pharmaceutical care with the activities,
interventions and responsibilities it involves. Researchers should develop
methods for measuring outcomes and conduct well-designed evaluative studies
and sound economic studies. In addition, pharmacists should develop the
research skills to conduct such studies and be prepared to work together
and share their findings.
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