Hospital Pharmacist
Vol 9 No 10 p284
November 2002

News summary

Many patients are not receiving essential regular medicines before operations

Essential regular medicines are not being given to a large number of patients before their operations, according to data collected as part of the National Confidential Enquiry into Perioperative Deaths (NCEPOD).

A sample of all the perioperative deaths reported to the enquiry was examined to determine how many patients were on maintenance drug treatment for medical conditions and whether drugs were given on the morning of an operation. The percentage of cases where drugs were not given before urgent, scheduled or elective operations was recorded (see Table 1).

The NCEPOD 2001-02 report, entitled "Functioning as a team", says that, for emergency cases, an omission of maintenance drugs may be unavoidable. However, most of the urgent, and all scheduled and elective patients, should be able to take their maintenance drugs on the morning of the operation.

The report says: "It is interesting that giving thyroid-related medication on the day of the operation appears to be a low priority. Of concern, is the information on antianginal, bronchodilator and steroid therapy. These drugs should be given throughout the operative period and when the patient cannot take their oral drugs, there are simple topical, inhaled or parenteral replacement formulations readily available."

Some of the drug charts looked at by the enquiry show that the reason given for patients not receiving their drug is because they were classified as "nil by mouth" for the pre-operative period. The report says: "Doctors and nurses need to understand the difference between preoperative oral medication and the full English breakfast."

Stephen Brough, principal pharmacist for surgery, St Helens and Knowsley Hospitals NHS Trust, Prescot, told Hospital Pharmacist that accurate drug history taking in pre-admission clinics or, in the case of elective surgery in pre-operative clinics, could help clarify the medication required during an inpatient stay and go some way to avoid doses being missed. He said that not all surgical admissions units had a pharmacist to take drug histories and, in some cases, this could be because of a lack of funding.

Mr Brough said: "Drug history taking is a low priority for doctors, and pharmacists are better at it anyway." He added: "Unambiguous prescriptions are essential, and pharmacist transcribing might help with this."

Mr Brough said that, although pharmacists monitored drug charts on wards, it was not always possible to see charts pre-operatively in some cases, such as emergency admissions.

He pointed out that anaesthetists usually decided which medicines could adversely affect surgery and, therefore, which should be stopped preoperatively.

A "nil by mouth"policy written jointly by anaesthetists and pharmacists, together with awareness training programmes for nursing staff, may help resolve some of the problems, he said.

The report also calls for national guidelines for prescription writing in hospitals to be established in order to reduce drug errors. Dose alteration on prescriptions is not uncommon, it says, but it is often not possible to know the time or date when the alteration was made, or who made it.

The report suggests that new signed and dated prescriptions should be made when doses are altered so that the sequence of prescribing events can be clarified and errors reduced.

Although there are prescribing guidelines in the British National Formulary, the report says that these relate more to prescribing by general practitioners. It adds: "The amount of training in writing clinical prescriptions given to medical students varies between medical schools. The amount of training in writing clinical prescriptions given to postgraduate doctors during their induction to a new appointment varies between hospitals."

The report says: "Increasingly, hospital pharmacists are monitoring drug prescriptions and they are qualified to determine the clinical suitability of a prescribed medicine. Experienced nursing staff should be encouraged to question prescriptions if they have concerns."

Copies of the report can be downloaded from the NCEPOD website (www.ncepod.org.uk) or ordered (price £20 including packaging and post) from NCEPOD, 35-43 Lincoln's Inn Fields, London WC2A 3PE.