Hospital Pharmacist
Vol 9 No 5 p122
May 2002

Risk management — do we have a wide enough perspective?

By Richard Needle, PhD, MRPharmS

Risk management is a fundamental part of a pharmacist's responsibilities. Use of medication (the most common health intervention) is always a risk versus benefit balance, and it is a key element of our role to ensure that the balance is always to be as beneficial to the patient as possible. We achieve this by ensuring that the most appropriate drug is prescribed, at the right dose and frequency, and that it is correctly dispensed and administered in a timely manner. We should also ensure that the patient is as well equipped as possible to continue the treatment safely and effectively at home, by means of education and with such aids and supports as may be necessary.

However, the pharmacy perspective on risk management with regard to medicines is not the only one, and we need a holistic view and to take into account other people's judgments where valid and appropriate. A recent article on investigating clinical risks and the use of patients own drugs on surgical wards¹ and subsequent correspondence² led me to wonder whether we always take a wide enough perspective — do we always have a patient perspective?

In a community pharmacy with a regular clientele, the pharmacist subconsciously undertakes a risk assessment on, for example, how much detailed information is needed when Mrs Jones presents her otherwise regular prescription, but with a change to the diuretic treatment.The counselling is intuitively tailored to the perceived needs of the patient.

In Essex Rivers Healthcare NHS Trust we have universal availability of self-administration of medicines across the trust, and this is a key situation where the patient perspective needs to be taken into account.

When I sat down to talk to Mr Smith about his medication on admission, I did not have the luxury of a long relationship with him. When I first met him, I asked to see his medicines and he presented me with five part-used, blister strips and told me that he just carried the strips around because they fitted neatly into the small bag in which he likes to keep them. He knew he was only in hospital for 48 hours and he explained to me in detail what he took his medication for, when he took it and his arrangements for further supply. Should I have taken his medicines away from him and insisted on placing them in new, correctly-labelled containers? What effect would that have had on Mr Smith's attitude to his medication, his hospital episode and the pharmacy service?

Self-administration schemes empower patients and a holistic risk management approach is essential. If this can be got right, it will help with concordance, and we must allow patients to manage medicines in their own way provided we, as professionals, can satisfy ourselves that it is safe for them. All this requires a conscious and rational approach to risk assessment. It is not satisfactory just to rely on a subconscious or intuitive assessment, but equally, it is very difficult to cover all potential scenarios in a detailed, standard operating procedure to enable a totally consistent approach.

Arguably, self-administration of medicines broadens the range of risk that is apparent to the health professional. If Mr Evans cannot look after his medicines in hospital, because he cannot remember which ones to take and when, this is another element of risk that needs to be managed. However, we can take steps to manage it. Whereas, if the medicines were just administered from a trolley by the nursing staff, we would not even be aware that the risk existed until, perhaps, Mr Evans was re-admitted with problems resulting from either overdose or missed doses of his prescribed medication.

A similar conscious, rational and holistic approach to risk assessment of injectable therapy needs to be undertaken as well, and this was the main thrust of a recent Hospital Pharmacists Group article.³ Pharmacists need to be responsible for undertaking a pragmatic risk assessment of injection preparation in the wards and other departments of the hospital, and of the types and complexity of the injection preparations that are undertaken. An assessment then needs to be made of which elements of this should be undertaken by the pharmacy, and then a case made to secure the necessary resources. However, if the pharmacy service is only going to operate between 9am to 5pm, Monday to Friday, and is going to make a high proportion of intravenous preparations during that time, is this going to increase the risks of injection preparation outside these hours by de-skilling the nursing staff? Would it therefore be better, in some situations, to invest time and effort to increase the competence of nursing staff, and invest money on improving facilities and standards of preparation in clinical areas, as suggested in the recent award-winning work by Alison Beaney?⁴ This is a risk assessment that pharmacy must undertake.

Similar analyses of risk need to be undertaken in other areas where there are developments of pharmacy practice. For example, using pharmacy staff, instead of junior doctors, to take medication histories on admission is seen as a means of risk reduction, which indeed it is, but how wide a risk assessment perspective has been taken? A fundamental part of the junior doctor's role is training. They need to learn how to take a good medication history; when to be suspicious of the information; when to follow up and check, and how, and when to ask for help from senior medical colleagues or pharmacists. If we have pharmacy staff involved in medication history taking, then education of the junior doctors needs to be an integral part of that role. The same principles should also apply to pharmacists involved in discharge prescribing.

All health professionals, and indeed people in all walks of life, undertake intuitive risk assessments all day and every day. However, in the professional environment, where we are responsible for the management of medicines, we need to make more effort to undertake conscious riskassessments, and we must be wary of taking too narrow a professional view.

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