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The “yellow book” lists results and
anticoagulant doses
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Pharmacists should not assume that prescribers have undertaken all appropriate
safety checks when prescribing anticoagulants, the National Patient Safety Agency
warned in March last year (2007).
Instead, the NPSA said, pharmacists in England and Wales should ask to see patients’ latest
international normalised ratio (INR) test results before dispensing repeat prescriptions
for anticoagulants.
“Reviewing the patient-held record, which includes
the date of the last clinic appointment, the latest INR test results and current
dose, and confirming this information with the patient, is recommended as safe
practice,” the NPSA said.
The agency proposed the advice in response to
a series of reports of patient safety incidents involving anticoagulants
received from all sectors of the NHS in England and Wales. Patient safety alerts
The recommendation was included in a set of patient safety alerts covering
five areas of medicines management: anticoagulant therapy; injectable
medicines; epidural injections and infusions; paediatric intravenous
infusions; and liquid medicines administered via oral and other enteral
routes. The alerts
were issued last March (PJ, 31 March 2007, p356)
and the NPSA gave NHS and independent sector organisations in England
and Wales until the end of March 2008 to implement the recommendations.
Guidance for community pharmacists on anticoagulant therapy was sent
out as an
insert to The Journal in April last year. This gave basic information
regarding INR
monitoring.
Bruce Warner, senior pharmacist at the NPSA, explains that pharmacists
should check that monitoring is being carried out and that each patient’s
INR is at a level that would be safe to dispense the prescription. Target
INRs should be available in the patient-held record (the “yellow
book”), he points out.
A situation in which a patient, or the patient’s representative,
does not have this information is no different from any other dispensing
situation in which critical information is not available, Dr Warner stresses. “It
is important that patients do not go without important medication, although
as in other situations pharmacists must satisfy themselves that it is
safe to issue the prescription,” he says.
Clinic contact details should be available on the alert card provided
with the patient-held record, and pharmacists are encouraged to keep
these details on record, he adds. “If the prescriber is not contactable
and the patient does not have the record then it is up to the professional
judgement of the pharmacist as to how to proceed,” he says. “This
would normally be treated in the same way as any other dispensing with
an outstanding query.”
If a patient refuses to show the details to the pharmacist then the pharmacist
concerned must still make a professional judgement as to whether or not
it is safe to proceed with the dispensing, Dr Warner says.
Sadia Khan, lead pharmacist for self-care at Royal Pharmaceutical Society,
says that although community pharmacists should normally ask to see patients’ latest
INR results before dispensing repeat prescriptions for anticoagulants,
they should use their professional judgement where this information cannot
be obtained.
Other recommendations
The NPSA guidance also sets out a number of other actions pharmacists
should undertake to reduce the potential for harm to patients taking
anticoagulants.For instance, pharmacists should ensure patients or
their carers have received a patient-held record and fully understand
its contents.
In addition, if pharmacists dispense additional medicines
which might interact with anticoagulants (to patients already on anticoagulant
therapy), they should check that arrangements have been made for additional
INR tests.
The NPSA patient safety alert also says that it is safe practice for
all dose changes to be confirmed in writing by the prescriber. Dr Warner
says that a fax or an e-mail would be acceptable as long as there is
a copy of the changes available as an audit trail.
“In most cases the dose change would be reflected by a new prescription,
but where a dose change is made and a new prescription not issued then
a copy of the revised dose order should be retained,” he says.
“In
the case of an e-mail this could be printed out and retained. What should
be avoided are dose changes made verbally and not backed by a hard copy.” Further information
Further information about the NPSA’s recommendations on anticoagulant
therapy, including electronic versions of all the alerts and supporting
materials is available online
Assessing implementation
Primary care trusts will assess implementation of
the recommendations in community pharmacies. PCTs will self-declare
their current
stage of implementation of the alert as a whole through information
returned to the Department of Health through the Safety Alert
Broadcast System. It will be up to individual PCTs to decide
how they will assess implementation in order to complete these
returns accurately, Bruce Warner, senior pharmacist at the NPSA,
says.
In addition, all NHS organisations will be asked to assess implementation
of the alert recommendations and safety indicators and return an
audit to the NPSA. Dr Warner says that this is likely to be done
in April to June this year and that trusts may well ask clinics,
practices and community pharmacies for data so that they can complete
these audits.
He adds: “The results of these audits should
also form part of an annual report on medicines management presented
by NHS organisations to their own drugs and therapeutics or area
prescribing committees (or equivalent), thus enabling local monitoring
of implementation. It is also likely that the Healthcare Commission
will pick up implementation of the alert recommendations as part
of their routine checks on NHS trusts.” |
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The
Pharmaceutical Journal