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Patients and their medicines In hospital: a joint report from the National Pharmaceutical Forum and the Scottish Medical and Scientific Advisory Committee

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4 THE PATIENT EXPERIENCE

4.1 INTRODUCTION

People should be supported by the healthcare team to participate in their own care and be able to make informed choices about their treatment. 9,10

A process map is presented (see figure1) to illustrate the ideal journey for a patient from pre-admission to discharge through the processes and systems involved in the prescribing, supply and administration of medicines. By assuming the role of the patient and 'walking through' the map it is possible to identify key components which will identify how systems can be redesigned to improve service delivery and the patient's experience. These components are: review; admission; prescribing; supply; storage; administration and discharge.

This chapter presents the standard and criteria to support the development of patient-focused services.

4.2 THE STANDARD

The NHS in Scotland will make medicines available to meet the clinical needs of patients and wherever possible actively involve patients, parents and carers in making decisions about their medicines and that of their children.

4.3 THE CRITERIA

Criterion 1
To support safe prescribing a comprehensive medication review is an integral component of a hospital admission

Rationale

The medication review is an intellectual step in the prescribing process. A comprehensive medication review will ensure that:

  • Key clinical care needs are identified.
  • The medication history is complete.
  • Delayed treatment, due to missed doses of medication, or omitted medicines, is avoided.
  • Unnecessary dispensing and supply is avoided.
  • Duplication of administration is avoided.

A comprehensive medication review helps in establishing if the admission is due to a medication-related problem, contributes to the patient assessment and supports the development of care plans. It is recognised that up to 15% of hospital admissions are as a result of adverse drug events.

Discussion with the patient and/or their carer should include consideration of all therapies the patient may have had access to, for example herbal medicines, homoeopathic medicines and substances of abuse, and should identify the patient's concordance with their medication.

The medication review requires access to clinical data and the patient and/or carer, and should be informed by a full medication history. A medication history involves the collation of information from across the healthcare system including access to prescription and dispensing records, including over the counter ( OTC) purchases. Sensitivities and allergies to medicines must also be considered.

Fig 1: Patients and Their Medicines - Process Map

Fig 1: Patients and Their Medicines - Process Map

Whilst it is possible to have access to medication records, it is rare to have access to the administration record. For vulnerable, at risk patients and those medications which are not administered daily it is valuable to have the administration record. Information detailing last administered dose is essential for certain categories of patients, for example those receiving depot therapy or drug misusers on methadone to ensure appropriate continuity of care.

Recommendation

Clinicians* must develop models of practice to ensure that a comprehensive medication review is undertaken for all patients before or at admission.

* clinician is defined as a healthcare professional who is engaged in the direct examination, treatment and care of patients.

Criterion 2
Patients are encouraged to actively participate in prescribing choices and decisions about their medicines.

Rationale

Patients should not be passive recipients of prescribing decisions. Patients need to understand their medications so that they can get the full benefit from their therapy and reduce the likelihood of medicine-related problems. Any new medications commenced in hospital must be explained to patients and/or their carers.

Recommendation

Clinicians must ensure that patients are supported to learn about, and take responsibility for, their own medication.

Criterion 3
Systems are in place to ensure that medicines that are required for patient care are available at the point of clinical need.

Rationale

There are various options for the supply of medications to wards/departments and patients. Traditionally, hospital wards have held a stock of medications for use during the in-patient stay and a subsequent seven-day supply of medicines has been dispensed on discharge.

There is a requirement to create a medicine supply system that recognises the patient as the control point and the focus of healthcare activities, thereby facilitating seamless care and patient empowerment.

Procurement strategies should be further developed at local and national level to maximise use of NHS resources.

Recommendations

NHS Boards should review pharmacy supply arrangements and operating hours in the light of The Right Medicine: a Strategy for Pharmaceutical Care in Scotland to ensure that service and patient needs are met.

NHS Boards should promote clinicians and departments responsible for the procurement of medicines in primary and secondary care to work closely together to maximise cost-effective methods of purchasing medicines within agreed national purchasing frameworks.

Criterion 4
To support patient empowerment and aid continuity of care, patients should have their own individually dispensed supply of medicine.

Rationale

NHS organisations must ensure dispensed medicines meet the requirements of EEC Directive (92/27/EEC).

The traditional dispensing practice of breaking down bulk packs in the pharmacy is incompatible with the provision from the manufacturer of packaging for which a validated medicine expiry is known. Dispensing medicines in the manufacturer's original pack improves patient acceptability; patient compliance; security; child resistance; medicine stability; hygiene; stock control; labelling; traceability and accountability; and information for patients. 11-13 It also reduces dispensing time; medication and dispensing errors; and wastage in medicines. 11 Potential benefits were described by the Department of Health 14 and include faster discharge process, less changes for patients in their medications, improved patient convenience and the achievement of a patient-focused supply system.

Automation of medicine supply processes has shown benefits in improving patient safety and efficiency of the process. The potential for automation of this process should be explored.

Recommendations

NHS Boards should redesign their supply systems to optimise use and minimise risk in the use of medicines.

NHSScotland should consider the role of automation in streamlining the system for medicines supply.

References

  • EEC Directive (92/27/EEC)
  • Scottish Executive Health Department. The Right Medicine: A Strategy for Pharmaceutical Care in Scotland. Edinburgh, Astron: 2002.
  • Audit Commission. A Spoonful of Sugar - Medicines Management in NHS Hospitals. London: Audit Commission for Local Authorities and the National Health Service in England and Wales, 2001.
  • Scottish Intercollegiate Guidelines Network ( SIGN). The Immediate Discharge Document: A National Clinical Guideline. Edinburgh: SIGN, 2002.
  • Department of Health. Guidelines for the Safe and Secure Handling of Medicines (Duthie Report) London: 1988. [This document is currently under review by the Royal Pharmaceutical Society.]

Criterion 5
Patients are supported and encouraged to take an active role in managing their own care and to take responsibility for their medication including, where appropriate, self-administration of medicines.

Rationale

Traditionally, in hospital, patients have had their medications administered to them, and this will continue where medication regimes are complex or for those patients for whom self-administration of medicines is assessed as inappropriate. Self-administration schemes should however be supported where possible.

To ensure patient safety, medication self-administration schemes must encompass risk assessments of the patient, the therapy involved and the environment in which the scheme is going to operate.

The medication self-administration scheme must work to encourage patients to understand and manage their medicines. To achieve this requires explanation of medicine choice and formulation; instruction on dosage frequency, time of administration and duration of therapy. Patients participating in self-administration schemes need to recognize their responsibility in relation to their medicines within hospital.

Recommendation

NHS Boards should implement suitable medication self-administration schemes that empower patients to take an active role in managing their medicines.

Criterion 6
Medication to be continued after discharge from hospital is planned with the patient/carer.

Rationale

Patients' post-hospital needs should be identified during their in-patient stay and appropriate action taken to ensure continuity of care. Discharge must be planned with the patient and/or carer. The absence of such planning may lead to:

  • Inefficient discharge resulting in delay to patients going home.
  • Patient confusion after discharge.
  • Poor communication between primary and secondary care.
  • Uncertainty by the primary care team after discharge.

Communication across the hospital/community interface is prone to breakdown. Effective and clear communication is required to ensure that all prescribing decisions taken in hospital are fully understood and supported by the primary care team.

Where medicines are highly specialised they may be unfamiliar to general practitioners, community pharmacists and other members of the team. There is a requirement for a consistent approach across NHSScotland for clinical and prescribing responsibilities, as patients may journey between Health Boards.

Hospital staff must ensure that the patient and/or their carer is supported to understand their medicines and how to use them so that they can get the full benefit from their therapy.

Although electronic communication is being developed, existing paper-based systems must be strengthened to ensure effective communication is achieved with general practices and community pharmacies to ensure medicines are available to maintain continuity of care on discharge from hospital.

Recommendations

NHS Boards must demonstrate that there is effective discharge planning and communication in relation to medication with the patient and/or carer and the primary care team, including community pharmacy.

Clinicians should further develop shared care protocols for specialist medication.

References

  • Scottish Intercollegiate Guidelines Network: The Immediate Discharge Document 65 January 2003.
  • NHS Circular No.1990( GEN)11: Responsibility for Prescribing between Hospitals and GPs (March 1992).