Hospital Pharmacist
2007;14:196-197
June 2007

Guild of Healthcare Pharmacists / United Kingdom Clinical Pharmacy Association

New pharmacy body must be flexible

Chief pharmacists from the UKs four home countries gave their
perspectives on forthcoming
developments for the pharmacy profession at the opening session of the GHP/UKCPA joint conference, held in Brighton recently.
The formation of a General Pharmaceutical Council will have a dramatic impact on the Royal Pharmaceutical Society, said Keith Ridge, chief pharmaceutical officer for England, and much needs to be driven forward in preparation for this. He called for pharmacists to take the lead where medicines are involved (see Hospital Pharmacist 2007;14:147).

When asked how pharmacists might be persuaded to join a future body akin to a royal college, Dr Ridge said that the profession should pull together and create a flexible organisation that people want to join. Bill Scott, chief pharmaceutical officer for Scotland, pointed out that if membership of the college helped pharmacists to undertake continuing professional development and revalidation then they would be likely to join. Carwen Wynne Howells, chief pharmaceutical adviser for Wales, added that pharmacy has the opportunity to create “a flexible vibrant organisation” that meets its needs.

Panel members acknowledged that younger pharmacists want to deliver clinical services but are often held back by “more traditional elements of the profession” and suggested that the future professional body should engage young pharmacists at an early stage. Norman Morrow, chief pharmaceutical officer for Northern Ireland suggested that some “pharmaceutical evangelism” might be needed here.

The planned redesign of professional services might call for some sacrifices to be made, Dr Morrow said. “This is not about takeovers or about cosmetic rearrangement — we must preserve and retain what is good, for example, the integrated inspection arrangements in Northern Ireland”. He urged radical thinking. “Consider a College of the Isles to serve all four home countries and a college of pharmacy leadership in the European Union — which might even attract intergovernmental support”, he said.

Dr Scott said: “We want a royal college to serve our profession and not merely to emulate other royal colleges.” Prescribing rights bring both opportunities and responsibilities and a learned body is needed to support pharmacists in this arena. Dr Scott emphasised the need for strong leadership to deliver the vision and to advocate professional pharmacy skills to patients and to paymasters. This would be one of the roles of a future college. The college should be based on scholarship, knowledge and learning and should reflect its constituents’ ambitions, he said. It would also gain strength by engaging with academics. All organisations should now be considering what they could bring to the future royal college. It is important to acknowledge that all contributions are valid, and also that some loss of identity and autonomy (for existing organisations) is inevitable, said Dr Morrow.

Ms Wynne-Howells said that existing pharmacy organisations, such as the GHP and UKCPA have much to contribute to a future college.

End-product testing of TPN

This year’s Pfizer patient safety award was given to Victoria Magnal, head of aseptic services at Royal Liverpool Children’s NHS Trust for a project that concerned the use of end-product testing as a quality assurance measure for paediatric TPN solutions.

Accidental mix-ups of small volume additives could lead to large changes in final concentrations of critical components, such as glucose, that could have serious clinical consequences, explained Ms Magnal. The situation is further complicated because nutrient concentrations are progressively increased over the first few days of intravenous feeding in neonates. For example, if dextrose and water were accidentally switched, on day 1 the final solution would contain 34 per cent dextrose instead of 8 per cent, but by day 4 it would contain 3 per cent instead of the intended 19 per cent. This could put the patient at risk of hyperglycaemia at first and then at risk of hypoglycaemia later, she said.

A variety of analytical methods had been tried including measurement of refractive index, osmolality and chemical analysis. So far no single method that could detect all potential errors had been found. A satisfactory method to detect a mix-up between water and amino acids is still needed, said Ms Magnal.

Prescribing skills of junior doctors

Gillian Cavell, deputy director of pharmacy, medication safety, at King’s College Hospital NHS Foundation Trust, London, was the winner of the GHP/UKCPA joint poster award, sponsored by Sanofi Aventis.

Ms Cavell compared the prescribing skills of second year foundation (F2) junior doctors, who had done their first year foundation (F1) training at other trusts, with the skills of F1 junior doctors who had recently attended the F1 safe prescribing workshop held at KCL. The F1 trainees scored better than the F2 trainees. Ms Cavell concluded that until F1 training is standardised, the F2 training programme at KCL will need to include more core F1 elements.

An electronic administration system — lessons learnt

Installation of a new closed-loop medicines administration system involving computerised physician order entry (electronic prescribing) and the use barcode scanners at the point of administration has reduced drug administration errors at Brigham and Women’s Hospital, Boston, US. Paul Szumita, clinical pharmacy practice manager at the hospital, described the benefits of the system and focused on the lessons learnt during implementation.

Introducing the new technology has reduced wrong medicine errors by 56 per cent, wrong dose/strength errors by 71 per cent and wrong dosage form errors by 90 per cent, he said.

Mr Szumita explained that one of the reasons that errors still occur despite the new system is because of staff “work arounds” — when staff bypass the proper working systems to fit in with their workflow.

Pharmacy staff work arounds include:

• Not scanning each item dispensed, but scanning the same item multiple times

• Cutting and pasting information from the database into the dispensing system rather than typing it in

• Photocopying barcodes

• Missing out the final scan and sending the product to the ward with the intention of “dealing with it later”

Nursing work arounds include:

• Not scanning the drug

• Not scanning the patient’s wrist band at the bedside

• Not scanning at all (using the system’s emergency procedures to avoid having to scan)

• Giving drugs from a “stash” and scanning them all in together after administration is complete

For these reasons it is important to understand staff workflow and how new systems can be best integrated into these, said Mr Szumita. He recommended that staff be involved at an early stage in the screen design, staff training and decisions about implementation. Education and training costs were higher than they had initially expected, he said, but good training is essential for the success of the system. Extreme variance in staff acceptance of such a system is also to be expected, he warned.

Mr Szumita added that it is important to be aware that the initial system will need modifying during implementation — at Brigham and Women’s Hospital 44 changes were made to the software for the electronic prescribing system before they were happy with the way it worked.

Chief pharmacists' roles may expand

In the future there will be prescriptions for both medicines and knowledge and the chief pharmacist will be the chief knowledge officer for medicines, according to Sir Muir Gray, director, National Knowledge Service.

He also predicted that drug budgets would become a thing of the past and be replaced by programme budgets. Chief pharmacists would then work with other health care professionals on overall programme budgets of which medicines would be a part, he said.

Sir Muir also described a new medicines knowledge base being developed by the National Electronic Library for Medicines (NeLM) for both patients and prescribers that is due to be tested shortly. Alongside this development, “national knowledge weeks” will be implemented. The top 50 health problems will be the subjects of the first series of these, he explained.

Other features of the new NeLM website will include the facility to target information more effectively so that “everyone does not get everything all the time”, and the option to collate information, such as clinical guidance and patient information, about each medicine.

David Erskine, acting director, regional medicines information centre at Guys and St Thomas’ NHS Foundation Trust explained that a “book club” approach might be used to enable users to discuss a specific publication online.

New UKCPA chair

Catherine Duggan, associate director of clinical pharmacy, development and evaluation for London, South East and Eastern and a senior clinical lecturer at the University of London School of Pharmacy has been appointed chair of the UKCPA.

Modernising pharmacy services

Andrew Alldred, director of pharmacy and medicines management at Harrogate and District NHS Foundation Trust is the winner of this year’s TEVA leadership award.

Mr Alldred described how a project designed to increase efficiency, modernise processes and improve patients’ access to medicines had been implemented.

Harrogate General Hospital is a 400-bed hospital that has been rated as one of the top-performing NHS organisations. Expenditure on medicines, currently £4.7m annually, is growing at a rate of 12 per cent per annum.

The project, based on feedback from staff, involved modernisation of three elements of the service — inpatient dispensing, individual patient dispensing (IPD) and clinical pharmacy services. Pharmacists in the department had recommended greater use of technician checking and the removal of the supply function from the pharmacists’ role on wards.

Before implementation of the project, clinical pharmacists had devoted much of their time on wards to supplying medicines. Now pharmacy technicians handle supply issues, leaving pharmacists free to deal with clinical tasks such as taking drug histories and patient education.

“Setting the direction and articulating the vision to stakeholders was the key to success,” said Mr Alldred. “Leading the changes through frontline staff also emerged as an important way to do things.”

By the end of the project the number of discharge prescriptions checked at ward level had increased from 20 per cent to 65 per cent. Average dispensing times for TTOs had decreased from 86 minutes to 60 minutes. Additional checking technicians and two medicines management technicians had been appointed. In addition, savings through the reuse of patients’ own medicines amounted to about £130,000 per annum.
“
These types of changes could be reproduced in many organisations,” said Mr Alldred.