Hospital Pharmacist
Vol 11 No 8 p339-340
September 2004

Intensive pharmacy input at admission — A pilot project

By Kajal Shah, BPharm, MRPharmS, Richard Needle, PhD, MRPharmS, Tracey Foss, DipClinPharm, MRPharmS, Kieron Watson, BPharm, MRPharmS, Nicola Allsopp

Studies undertaken in UK hospitals have shown that medical prescribing on admission quite often contains inaccuracies that can adversely affect patient care and, in some cases, carry significant risks of increased morbidity.^1,2 A small study undertaken locally showed an inaccuracy rate in excess of 40 per cent, much in line with the published studies. It is also acknowledged that somewhere between 6 per cent and 45 per cent of hospital admissions may be related to the adverse effects of medicines.³

The Government has placed emphasis on the need for safe and effective use of medicines and avoidance of medicines-related morbidity. The report “Building a safer NHS for patients: Implementing an organisation with a memory” laid out specific targets, including a reduction in the number of serious errors in the use of prescribed drugs by 40 per cent, by 2005.⁴ The recent publication “Building a safer NHS: Improving medication safety” cited a range of recommendations including pharmacy input at admission.⁵ Standards 22 and 23 of the Department of Health framework for Medicines Management in NHS Hospitals (2003) requires pharmacy in England to undertake full medication reviews within 24 hours and to assess at an early stage which patients need higher levels of clinical pharmacy input.⁶

Against the background of this national agenda and local concerns about prescribing accuracy, there were other identified issues of concern. These included the delays in obtaining medicines for acutely ill patients or those being discharged directly from the medical assessment unit (MAU) and the number of patients’ medicines being mislaid during transfer from the MAU to other parts of the hospital. Concern was also expressed about the level of the pharmacy service and when it was available. The MAU is busy well into the evening and this view is supported by data from hospitals with electronic prescribing systems showing that prescribing continues at a high level long after traditional closing times for pharmacy departments.⁷

Structure of the pilot

With funding support from local primary care trusts (PCTs), a three-month service of intensive input to the MAU was run from September to November 2003. A clinical pharmacist and a pharmacy technician, trained using our locally developed course,⁸ were present on the unit from 7am until 8pm seven days a week. As it was a pilot project experienced permanent staff, who worked significant overtime, undertook the project with their main duties covered to some extent by locum staff. The pharmacy staff obtained and recorded accurate medication histories and compared these with those obtained by the junior doctors, intervening where necessary. The interventions were rated as being of low or high significance, and the ratings were moderated by senior clinical pharmacists. The project staff provided pharmaceutical support to post-take ward rounds and the pharmacy team also ensured timely supply of medication on admission, identified and reported definite and possible medicines-related admissions, and counselled patients discharged directly from MAU on the safe and effective use of their medicines. They also contributed opportunistically to the education of nurses and junior doctors as appropriate.

Outcome of the project

On average, the project team saw 145 patients per week, which was 87 per cent of the total patients admitted to the unit. Of these, 8 per cent of admissions were judged as definitely related to their medication and a further 10 per cent were possibly linked. Fifty per cent of all admissions seen were GP initiated, and 75 per cent of these patients came with a letter. However, 39 per cent of letters were found to contain inaccurate or incomplete medication histories.

An average of 150 interventions was made per week. Most (62 per cent) were “near misses” as the interventions were made before a potential error could occur. Of these, 42 per cent were rated as highly significant. Interventions made after medicines administration, or omission, were split almost equally between those of low and high significance. Serious interventions included prescribing penicillins to allergic patients and omitting insulin prescriptions from diabetes patients and warfarin from patients with valve replacement.

Mis-prescribing included substituting statins for antidepressants, prescribing oral methotrexate daily and a patient admitted with a gastro-intestinal bleed who was prescribed aspirin and a non-steroidal anti-inflammatory product.

During the project, the pharmacy staff observed that the junior doctors tended to use only one source of information in taking a medication history, typically either the GP letter or through interviewing the patient and this was reflected in the interventions made. There was also a tendency not to take renal or hepatic function into account when writing the admission prescription, again resolved by pharmacy intervention. The project also demonstrated significant savings by the reduction in mislaid or misdirected medication.

Many patients responded positively to the service and an attitude survey completed after the project ended showed that it was universally well received by the medical and nursing staff of all grades who worked on the MAU. Particular benefits cited included the medication risk reduction, the timeliness of medication supply and the resulting reduction in discharge delay, the educational input on medicines and the marked reduction of mislaid medicines. Consultant medical staff specifically commented that the pharmacy input ensured that medicines were given appropriate attention in the MAU, which is a pressured working environment.

Future developments

As a result of this project, discussions have started with the local PCTs regarding the information provided by GPs. The aim of these discussions is to improve the accuracy of information, perhaps with a standardised approach. Discussions have also started with the hospital-based medical teams about improving the quality of prescribing on admission. A bid for funding a continuing service has been submitted, based partly on the savings made by the reduction in wastage.

Acknowledgements The financial support of Colchester and Tendring PCTs in funding the project is gratefully acknowledged, as is the commitment and hard work of the pharmacists and technicians who took part in the project, who gave up a significant amount of their time to make the project a success.

References

1. McFadzean E, Isles C, Moffat J, Norrie J, Stewart D. Is there a role for a prescribing pharmacist in preventing prescribing errors in a medical admissions unit? Pharmaceutical Journal 2003;270:896–9 (PDF 90K)

2. Drewett N. Stop regular medicine errors. Pharmacy in Practice 1998:8;193–6

3. Bhalla N, Duggan C, Dhillon S. The incidence and nature of drug-related admissions to hospital. Pharmaceutical Journal 2003;270:583–6 (PDF 90K)

4. Department of Health. Building a safer NHS for patients: Implementing an organisation with a memory. London: The Department; 2001

5. Department of Health. Building a safer NHS for patients: Improving medication safety. London: The Department; 2004

6. Department of Health. Medicines management in NHS Trusts: Hospital medicines management framework. London: The Department; 2003

7. Audit Commission. A spoonful of sugar — medicines management in NHS hospitals. London: The Commission; 2001

8. Foss T, Gant R. Development of a clinical pharmacy technician training course. Hospital Pharmacist, 2003; 10:9–10 (PDF 90K)