Meetings

UKCPA: progressing pharmacy

Designing practical policies, keeping abreast of advances in research and developing a peer-support strategy were all ways to progress pharmacy discussed at the United Kingdom Clinical Pharmacy Association's spring symposium held in Warwick from 9 to 11 May. Rachel Graham and Christine Clark report

Ms Graham is staff editor of Hospital Pharmacist and Dr Clark is a freelance medical writer and consultant pharmacist

Using amber oral syringes can reduce the risk of patients receiving oral medicines by the intravenous route, according to GILLIAN CAVELL, associate pharmacy director, King's College Hospital, London.

Describing work that won the Pharmacia patient safety award 2003, Ms Cavell said she was part of a multidisciplinary team that used failure mode effects analysis to calculate a "criticality index" for five scenarios involving administering oral medicines to patients with IV access. In calculating the criticality index, the team multiplied together scores for the likelihood of an error occuring, the severity of the outcome of that error, and the likelihood of that error being detected before the patient is exposed to it.

Using an amber oral syringe provides a visual alert, making it more likely that a potential error will be detected before a patient fitted with IV access and an enteral feeding tube receives a drug via the wrong route

Administering an oral medicine from an IV syringe to a patient with IV access, and administering an oral medicine from an IV syringe to a patient with IV access where the medication is to be given down an enteral feeding tube, have high criticality indices. Using a standard oral syringe instead of an IV syringe reduces the criticality index for the first scenario, but not for the latter, because the tip of the standard oral syringe needs to be fitted with a Luer adaptor before it can be connected to the enteral tube, which also makes it compatible with the IV access. For that scenario, using an amber oral syringe reduces the criticality index, because the colour of the syringe provides a visual alert, making it more likely that the error will be detected before the patient receives the drug by the wrong route Ms Cavell said.

Using amber syringes for oral medicines is now policy at King's College Hospital, and is approved by the trust's clincial risk management group. Barriers to implementation included difficulties in changing nursing practices, especially when bank staff were used, and concerns about cost. Regarding the former, the policy was widely publicised by putting posters on wards, handing out copies of the policy and starter packs to nursing staff and giving hands on demonstrations. Regarding the latter, Ms Cavell pointed out that the amber oral syringes were designed to be re-used by the same patient, and so using them might actually save money, even though they were more expensive than an IV syringe on a unit basis.

A full audit of adherence to the new policy has not yet been carried out. However, Ms Cavell said that the number of amber oral syringes issued has gone up by the degree that would be expected were the policy being adhered to. In addition, three months after the policy was introduced, 20 nurses who were selected at random and asked to estimate the risks of error in three of the five scenarios arrived at criticality indices broadly similar to those of the multidisciplinary group, suggesting that the risk reduction predicted by the multidisciplinary group reflected the opinions of nursing practitioners.

An ideal solution for reducing the risk of "wrong route" errors where patients have IV access and enteral feeding tubes would be to have standardised tubes and syringe tips such that only IV syringes could connect directly with IV lines and only oral syringes could connect directly with feeding tubes. But that was a long way off, Ms Cavell said, and in the meantime, using amber oral syringes provides a practical solution to the potential problem.

Pharmacogenomics

Advances in pharmacogenomics could lead to pharmacists being able to tailor drug therapy to suit a particular patient, giving the patient only those drugs that are safe and effective for someone of their genotype, according to Professor GILBERT BURCKART, chairman, department of Pharmacy, University of Southern California.

Delivering the Aventis lecture, Professor Burckart said that support for these conclusions comes from work he has done looking at the effects of genetic polymorphisms in the MDR1 gene (the gene encoding for p-glycoprotein, which pumps drugs in or out of cells, depending on the cell type) and the CYP3A gene (the gene encoding for cytochrome P4503A, which metabolises various drugs) on a patient's handling of immunosuppressive drugs used in transplantation. Patients with certain MDR1 genetic profiles have high levels of p-glycoprotein, and these "high pumpers" handle certain treatments in a different way from those with low levels of p-glycoprtein ("low pumpers"). For example, it is generally difficult to wean high pumpers off corticosteroids, but they tend to be responsive to induction antibodies, he said. High pumpers also pump out tacrolimus and ciclosporin, so it is better to give sirolimus or mycophenolate mofetil, which are not p-glycoprotein substrates. But if tacrolimus or ciclosporin are given to high pumpers, they tend to suffer less nephrotoxicity than low pumpers, because they pump out creatinine more efficiently. For the CYP3A gene, patients with certain genetic profiles require higher doses of tacrolimus to achieve the same blood concentration as patients with different profiles.

Pharmacogenomics is particularly important in states with low response rates, such as chronic graft rejection in transplantation. Professor Burckart pointed out that pharmacogenomics is not a new science. As far back as the 1950s, it was recognised that certain people could not metabolise suxamethonium due to a plasma cholinesterase deficiency. At the time, not much could be done with this information because the genetic technology was not available. Since then, many technological advances have been made, such as the sequencing of the human genome, but further advances, particularly in bioinformatics, are needed before the full potential of pharmacogenomics can be realised.

With their knowledge of drugs, pharmacists are in a good position to embrace pharmacogenomics, and deliver patient-focused therapy. The profile of pharmacists would also be enhanced, said Professor Burckart.

Peer support strategy

A peer support strategy could be a valuable aid to continuing professional development, according to LYNN BOLLINGTON, the winner of the 2003 Wyeth education and training award. The process of reflection is often easier with peers than with managers. Peer support is simply colleagues helping each other on a non-threatening environment — it is divorced from any appraisal process. This, in itself, is helpful because it is recognised that people learning for an assessment behave differently from people who are checking their own progress, explained Ms Bollington.

A peer support strategy involving 26 pharmacists was implemented at the Royal Glamorgan Hospital, Wales during 2001. As peer support relies on mutual support and commitment, an action research model was chosen, in which all the participants were fully involved. The first phase of the project was an assessment of the existing level of peer support and pharmacists' previous experiences of receiving feedback. This showed that there were few scheduled peer support activities. Informal discussions were useful to some but these were not available to all of the pharmacists because of their remote locations in the hospital. Everyone agreed that more feedback would be helpful. The majority felt that feedback from a manager was daunting and it would be less intimidating to receive it from a peer. There was general agreement that feedback needed to be timely, private and should provide the opportunity for two-way discussion. Anonymised feedback was felt to be unhelpful.

A programme of lunchtime meetings was started at which attendance was voluntary. The meetings were unstructured and based on discussions of cases. It was critical to created an atmosphere in which people could reveal their weaknesses and identify their knowledge gaps, explained Ms Bollington. In order to achieve this, the whole team agreed a set of ground rules based on honesty, openness, respect for others' views and a commitment to provide constructive feedback in a non-confrontational manner. When the scheme was evaluated, participants said that they had learned from colleagues' experience and had developed mutual respect for each other's expertise. "Even the quiet people seemed to come out," said Ms Bollington, and the meetings have continued after the end of the project.

Asked how the effectiveness of the programme could be proved, Ms Bollington said that each group member would get something different from it and the impact would eventually be seen in each individual's continuing professional development.