Hospital Pharmacist
Vol 9 No 7 p207-208
July/August 2002

DAVID COUSINS: thinker with a clear vision

By Bob Leach, MPharm, FRPharmS

In May, it was announced that Professor David Cousins had been appointed as the head of safe medication practices at the National Patient Safety Agency. He is due to take up this post in September.

In his new role, Professor Cousins will establish and develop a multidisciplinary team that will devise solutions to problems identified by analysing reported clinical incidents in relation to medicines use. This will involve commissioning a research programme and working closely with practitioners, patient groups, the pharmaceutical industry and other organisations to initiate changes leading to safer medication practice.

Few hospital pharmacists would be surprised at the choice of Professor Cousins for this role. The reason for this is clear from comments made to The Pharmaceutical Journal after his appointment. He says: "I have been working and publishing in the area of patient safety for 10 years or more, and I see my new position as an extension and development of that work."

This interest in patient safety, and especially in the identification, documentation and prevention of medication errors, was kindled in the early 1990s when a patient with a documented allergy to trimethoprim nevertheless received a dose of the drug that proved fatal. Thus, in 1993, along with Professor David Upton at University Hospitals of Leicester NHS Trust, he commenced a series of reports on medication errors in the journal, Pharmacy in Practice.

But a look at other aspects of Professor Cousins' career makes it clear that he has always been keen on "providing services to maximise the pharmaceutical contribution to the safe use of medicines and the reduction of medication errors."

After graduating from the University of London School of Pharmacy (ULSOP) in 1976, he undertook his preregistration training at Torbay Hospital, followed by a two-year grade 1 (basic grade) appointment at North Devon District Hospital, Barnstaple. He then spent four years (1979–83) as clinical services pharmacist at Orsett Hospital, Grays, from where he was seconded for one year to take the MSc in clinical pharmacy at ULSOP. He was appointed principal pharmacist and head of department at Derbyshire Royal Infirmary in 1983. In 1997, he was awarded a PhD in pharmacy practice by the University of Wales for a thesis describing the development and evaluation of an instrument to assure the quality of clinical pharmacy services in a district general hospital. Professor Cousins became chief pharmacist of Southern Derbyshire Acute Hospitals NHS trust when the Derbyshire Royal Infirmary and the Derby City Hospital merged to become a single trust in 1999. He also became chairman of the trust's medication error review committee.

CIVAS and DIVAS

Two key projects that Professor Cousins has been involved in are CIVA and DIVA (centralised and decentralised intravenous additive) services.

Parenteral medicines used in hospitals are expensive and can be associated with serious medication errors. Improving the systems for using parenteral medicines was identified as high priority for the pharmacy service soon after Professor Cousins arrived at Derby in 1983. At that time, nursing staff requested the drug and therapeutics committee (DTC) to take action to reduce the number of prescriptions for intravenous (IV) therapy being written by medical staff. The nurses were being overwhelmed by the increasing IV workload and did not feel confident preparing and administering these products.

The pharmacy department responded by analysing the situation and establishing a CIVA service for all infusions required in general ward areas including antibiotics, cardio- vascular agents, and for a number of other products that were causing problems. The nursing staff were pleased with this service as they no longer had to prepare infusions in ward areas and could focus on drug administration and direct patient care.

Professor Cousins was also responsible for overseeing the provision of a DIVA service for the cancer, medical and paediatrics directorates. A further development is a pilot scheme which will begin later this year on two wards, where pharmacy technicians will prepare and administer all IV therapy, as well as other medicines.

Electronic prescribing

Following his work on IV additive services, Professor Cousins then focused on increasing safety and efficiency in other areas of the medication process. The need to replace the pharmacy stock control computer system at the Derby trust in the early 1990s provided him with the chance to pilot an early electronic prescribing system.

Professor Cousins and his staff worked with JAC, a computer systems supplier, to define and develop an electronic prescribing system. The pilot was carried out on a general medical ward for 18 months between 1996 and 1998. The system provided the prescriber with a point-of-care knowledge database maintained and supplied by First DataBank Europe. The database provided warnings on medicine allergy, duplication of therapy, and significant drug interactions, on a need-to-know basis.

The trust is currently in the process of procuring a full electronic patient record (EPR) system. Professor Cousins believes that it is important for electronic prescribing systems used in the UK to be subjected to pilot and full research studies, in order to develop evidence of the benefits or otherwise of these systems. Professor Cousins hopes that electronic prescribing, along with pharmacist prescribing, will help to reduce medication errors due to poor or ambiguous prescribing.

Cardiac arrest

Professor Cousins has also helped to develop the role of the pharmacist on cardiopulmonary resuscitation (CPR) teams. Here again nurses were having to draw up, often dilute, and add drugs to IV bags as required.

In 1986, Professor Cousins received a United Kingdom Clinical Pharmacy Association award to study the role of the pharmacist on the hospital CPR team. This study involved visiting the US, where he spent two months at the University of Illinois, Chicago. He successfully completed a training course for team members and participated in his first CPR procedure. In 1987, Professor Cousins introduced a pharmacist member to the CPR team at Derby. A re-evaluation of the service performed 10 years later indicated that medical and nursing staff favoured the continued inclusion of the pharmacist on the team.

Technicians

Pharmacists can assist all members of the health care team to use medicines safely and effectively by helping to draw up policies and procedures. Professor Cousins believes that the use of well-trained pharmacy technicians to perform routine monitoring and triage of inpatient prescriptions can help to free up pharmacists to produce these policies.

"I see considerable potential in increasing the contribution of pharmacy technicians, recognising that one-to-one contact between clinical pharmacists and all patients under their care is unlikely to be achievable and is probably unnecessary. A more promising approach is for suitably trained pharmacy technicians to screen patients, taking appropriate actions within their competence and referring other patients to the pharmacist."

Professor Cousins' commitment to such training for technicians was underlined in his contribution to the development of a Business and Technology Education Council (BTEC) professional development certificate for clinical pharmacy technicians in 2000. About 20 students, mainly from the Old Trent region, were enrolled in the first cohort. Commenting on this group of students, who have recently completed the certificate, he says: "An almost evangelical spirit exists within the group."

Other areas

The contributions of Professor Cousins have also been evident in other areas, such as the selection of pumps and administration sets for use at the Derby trust. The pharmacy department has now centralised the storage and supply of infusion pumps, and has set up a "pump library service" and an ongoing training and troubleshooting service for intravenous administration procedures.

In addition, he is a visiting professor in pharmacy practice at the University of Derby. Some of the initiatives in which he is involved include planning and participating in the extended nurse prescribing training courses and multidisciplinary training on medicines for medical students in the new medical school at Derby.

Audit commission report

Professor Cousins has been pleasantly surprised that the Audit Commission report on medicines management leaned heavily towards improvements in medication safety and the central role of the pharmacist in this regard. He said that it contrasted with the data collection exercise for the report, which had seemed to concentrate on cost-effectiveness.

Although Professor Cousins believes that the report has great potential, he is worried that with the incorporation of the Audit Commission into the new Commission for Health Care, Audit and Inspection (CHAI), there may be no external body to drive the implementation. He comments that the chief pharmacist has to become recognised as the lead professional in a trust with responsibility for the safety of medication systems and to be accountable, both internally and externally. This would be analogous to the recognition that hospital infection matters are the responsibility of consultants in microbiology.

Professor Cousins believes that it is important for all trust chief pharmacists to give full attention to the document and agree an action plan within their trust for the implementation of each recommendation.

Looking ahead

Professor Cousins envisages that, in the future, hospital pharmacy practice will be increasingly focused on team delivery. He also believes that there will be changes in the use of information and automation. Most of all, there will be much greater emphasis on assuring the quality of use of medicines in hospitals. He says that, up till now, quality assurance has been a term confined to pharmacy manufacturing activities, but that in the future, the same philosophy will apply to all clinical processes in hospital, including medication use.