Hospital Pharmacist
Vol 11 No 1 p23-24
January 2004

Introducing a one-stop dispensing scheme at a mental health unit

By D. Smart

One-stop dispensing, the use of patients’ own drugs and self-administration of medicines were implemented for acute elderly care patients at Clacton and District Hospital in 1997. Having these practices up and running for patients in the acute trust highlighted a number of problems with the medicines administration practices at the mental illness unit in the hospital. For example, at the unit, many patients brought their own drugs with them the first time they were admitted but, because the medicines were not used, did not bring them in with them again if admitted for a second or subsequent time. This created risk management problems from two perspectives. First, admitting doctors often relied on patients’ own drugs as an important tool in obtaining a drug history on admission. Not having patients bringing in their own drugs therefore made drug history taking less reliable. Second, if medicines were changed during a patient’s stay, there was a risk that the patient would be confused when they returned home about whether to continue taking their previous drugs in addition to those of any new regimen.

A review of medicines administration practices on the acute mental health unit also highlighted a number of other issues of concern. At “medicine round” times, the patients were accustomed to queuing for their medicines by the drug trolley, while the nurses retrieved the drug items from the trolley and administered them. There was no confidentiality or dignity associated with this practice. Also, space within the trolley was not adequate for the quantity of medicines stored within it, increasing the risk of administration errors.

Mental health patients are often encouraged to take short periods of leave before their final discharge, as part of their rehabilitation assessment. The medicines for these leave periods are often required at short notice, frequently outside normal pharmacy opening hours, requiring a call to the on-call pharmacist for a supply to be made. Even during “normal” hours, patients would need to wait their turn at the busy dispensary among the routine outpatients.

It was therefore decided that a one-stop dispensing scheme, using patients’ own drugs could alleviate some of these problems, and create the potential for a future move to patients self-administering their own medicines. The most appropriate person to oversee the implementation was the dispensary manager, a pharmacy technician.

Developing the scheme

A draft proposal based on the scheme successfully implemented throughout the acute trust, was drawn up by the dispensary manager, endorsed by the senior pharmacy managers and then taken to the mental health unit managers. The manager of the acute mental health unit was enthusiastic about the potential of the scheme and encouraged the formation of a steering group, comprising the dispensary manager, a charge nurse from the acute mental health ward and a member of the clinical audit staff. The refined proposal was then presented by the dispensary manager to both the management executive committee of the trust and the consultant responsible for the unit, and approval was granted.

The next step was to identify a suitable storage area on the ward and source and purchase patient-specific medicine containers. Briefing sessions were then held with the nursing staff to gain their support for participation in the scheme. Competency-based training and assessment was carried out jointly by the charge nurse and the dispensary manager, covering both the issuing and checking the medicines for patients to take out on leave. Once training was complete, the ward trolley was removed and replaced by the medicines containers, stored in a central locked cupboard.

The scheme involves the pharmacy dispensing a fully labelled 28-day supply of medicines for each client, together with a duplicate empty container, which is labelled as for discharge. For medicines commonly used, “admission” packs are held on the ward. These have standard labelling, with spaces for the patient’s details. When these packs are used, the pack and prescription are sent to the pharmacy at the next opportunity for clinical screening and the supply of the empty duplicate pack. The purpose of the duplicate packs is to enable registered nursing staff (who have undergone the relevant training and assessment) to issue appropriate small quantities of medicines to patients for periods of short leave against a “to take out” prescription written by a doctor. The issue of medicines is checked by a second trained registered nurse, before medicines are handed to the patient. It was agreed that, when the pharmacy is closed, the prescribing doctor would take full responsibility for the accuracy of the “to take out” prescription but during pharmacy opening hours, a “fast track” clinical screen would take place, returning the prescription to the unit for the nurses to issue the medicines.

If medicines are altered during a patient’s stay, the treatment card and the patient-specific box of medicines is returned to the pharmacy for a clinical screen. Redispensing and relabelling is carried out as necessary.

At final discharge, all a patient’s medicines are returned to the pharmacy department, and the patient is given a 14-day supply to take home. This is a long-standing policy of the mental health trust. Mental health managers were not willing to allow the remainder of a patients’ medicines (ie, often more than 14 days supply) to be provided to the patient on discharge, because of the perceived risk of abuse.

Impact of the scheme

After some initial nervousness on the part of the nursing staff, the scheme is now well established at the mental health unit at Clacton and District Hospital. Nursing staff were surveyed after three months about their views on the training given and the operation of the scheme. There were no negative comments, and several nurses made positive comments about the ability to give a more flexible service to patients taking short leave.

The greater involvement of pharmacy staff in the mental health unit as a result of the scheme has improved multidisciplinary working relationships. The changes to the conduct of the medicine rounds have improved privacy and dignity for the patients. This is an issue identified as important in the National Service Framework for Mental Health.¹

After six months, the progress of the project was presented to a meeting of senior managers and consultants of the trust. The reception was positive. The trust’s management executive committee subsequently ratified the scheme and endorsed its adoption elsewhere in the mental health trust. This was recognition of the risk management benefits of a formalised protocol where specifically trained nurses are able to ensure that patients can take short rehabilitation leave from hospital with properly labelled and packaged medicines.

Future plans

Now that the one-stop dispensing scheme is well established, the next phase is to introduce a self-administration programme. This, as in the acute trust, will allow patients to be gradually introduced to managing their own medicines while still on the ward. The programme will be co-ordinated by the dispensary manager.

The self-administration programme will be another major culture change for staff at the mental health unit. It will, however, enable patients to be trained about how to be responsible for their own medicines before they are discharged. It will also allow staff to identify and resolve any potential risk issues in line with practices advocated in the “Spoonful of sugar” document.²