Practical advice for managing medicines in care homes (5 minute read)

November 14, 2019 By Steve Turner

The Patients Association has recently published a ‘Care Home Charter’ for medicines (link: http://bit.ly/2p1H76b). A key theme of the charter is medicines safety, which is the focus of this opinion piece.

Ensuring your Medicines Policy is accessible and can be used for training.

It’s worth considering how your policy links to staff training, and how accessible user-friendly it is. Are procedures outlined clearly in the policy? Do they link to Standard Operating Procedures [SOPs] and to competency assessments? Are they updated as the result of incidents and near-misses, and do you use checklists to make them easy to read, follow and audit?

Using this simple checklist can help ensure your policies are up-to-date, accessible and relevant, and don’t just sit on a shelf.

Click here for more information on the Care Right Now Speak Up For Learning approach to change.

Ensuring residents have at least 1 multidisciplinary medication review per year.

There is increasing help available from Clinical Commissioning Group Medicines Management Teams and Specialist Clinicians in this area.

These baseline actions can also help the review process:

This includes our useful resource page www.medsinfo.guru

Ensuring you have safe systems for administering and recording medicines.

It is vital that you have an accurate, accessible, legible and auditable system for medicines administration.

There has been a recent move by some of Pharmacies to change residential homes from Monitored Dose Systems [MDS] (also called blister packs) back to Original Pack Dispensing [OPD]. The reason for this, often given, is to improve safety. It is sometimes incorrectly implied that ‘guidelines’ are driving this move back to original pack dispensing, even bizarrely that OPD can help prevent polypharmacy & reduce medicines waste.

I have not been able to find any evidence that OPD is safer than MDS. The related NICE guidelines, quality standards and the CQC report ‘Medicines in Health and Social Care’ do not state this.

What’s important is that the home uses the safest system of delivering the medicines to the residents, considering the resident’s wishes, the home’s skill mix, the layout of the home, staff competencies, workload and capacity. This is particularly important as staff tell me original pack dispensing takes ‘twice as long’.

Bearing in mind that OPD takes longer, what are the advantages of moving to this? Can you be sure, for example, that unsafe practices such as ‘potting up’ will not creep into use?

My advice about MDS vs OPD is that if you are being lobbied to change to original pack dispensing, is to consider the questions set out below:

I am a nurse by trade and used to be a proponent of OPD in all circumstances. Since working in social care and with residential homes I’ve re-visited this view. I now believe that care home residents need well-designed systems and that, unless the resident can manage their medicines themselves (always the first consideration), a good MDS system is often a much safer way to administer medicines.

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A shorter version of this article first appeared in the Autumn Edition of The Carer.

About the author: Steve is a nurse prescriber, Head of Medicines and Prescribing for www.medicinegov.org , Information Governance Lead for CareMeds Ltd and Associate Lecturer at Plymouth University.

Contact steve@carerightnow.co.uk 07931 919 330. Related blogs & shared learning resources can be found here: www.patientled.education

Date: 14.11.2019

Using technology in care homes – eMAR

October 22, 2019 By Steve Turner

Introduction

Medicines errors in care homes are unacceptably high. A key study found that residents taking 7 or more medicines had a 79% chance of being a victim of a medicines error (Alldred et all 2009).

Best practice in medicines record keeping

The management of medicines in nursing and residential homes is part of a highly complex pathway. It involves multiple staff groups and organisations.

These include the G.P.; all who prescribe medicines and treatments; Care Staff of all grades; Support Workers; Consultants: Specialist Practitioners; and the Pharmacies who supply the medicines.

Benefits of electronic MAR charts

The benefits of implementing electronic MAR charts fall into three categories.

Improved legibility.
Improved access (e.g. if the charts are accessed and updated on a computer or portable device there is less risk of losing, damaging or mislaying them).
eMAR chart systems that obtain the data taken directly from the Community Pharmacy system eliminate the need for transcribing, which is a high-risk area.

In addition to the three benefits mentioned, carefully planned and implemented eMAR systems contribute to a decrease in medicines errors, reduced administrative costs and improved quality of care.

Challenges of implementing electronic MAR charts

There are three ‘bottom line’ challenges to manage when transitioning to electronic MAR charts.

1. Assessing the way the system works is critical, as poorly designed will not deliver benefits, and eventually fail.

The system must be easy to use and jargon-free; using only approved acronyms or mnemonics.

Electronic systems also offer the opportunity to introduce features that enhance safety, some of which, such as time-ordered charts, are difficult to include in a paper-based system.

Here’s a checklist:

2. It is vital that the system handles patient consent; patient confidentiality, system access; ownership of patient identifiable data; storage and transfer of data in a way which is compliant with the laws and regulations of your part of the U.K. This is an important question for you to pose to the supplier, particularly with the advent of General Data Protection Regulation (GDPR), and the new Data Protection Act 2018.

3. It is important to look at current processes and how the new system will work. There been problems where acute prescriptions were needed and supplied by a different pharmacy from the one providing the MAR charts, so the home ended up at times with an electronic MAR and a paper MAR. This causes confusion and increases the risk of errors and/or omissions. Colleagues have told me of instances where this has led to eMAR systems being abandoned.

Training and support requirements

Quality training and support, both during the implementation and on an ongoing basis, underpin all successful healthcare I.T systems and need to be planned from the outset. There are four areas that are sometimes overlooked, that deserve special mention.

1. Many of the users of eMAR systems will be Healthcare Assistants or other non-registered skilled staff. As a result, it will be important that the training they receive reinforces their duty to keep accurate records, and their accountability and role is made clear.

2. A significant number of staff may speak English as a second language. Therefore it is important that eMAR systems do not use any unnecessary jargon, and that any help text is in plain language.

3. Appropriate knowledge of Data Protection (GDPR) and Information Governance Rules and regulations are essential and should be built in to any training programmes.

Overall, consideration needs to be given to the nature and content of the training needed to implement the system, including how this is linked to the policies and procedures and overall governance of the home.

Good suppliers will be able to give advice and support on this.

Conclusion

Record keeping in medicines management is a critical safety area for care homes. The current high level of medicines errors is in care homes affects half a million people in England.

The prospect of implementing electronic systems for recording medicines administration holds great potential but is not itself without risk. It needs to be approached carefully in the light of the complex arrangements and multiple organisations involved in prescribing, supplying, administering and monitoring medicines in care homes.

In time, electronic systems will become the norm for medicines management in care homes.

Given the considerations over choice and implementation of systems, eMAR can overcome problems of legibility, transcribing, and access to records and information in a way that is not possible with paper systems.

In years to come it is likely that, just as most G.P.’s would not want to return to paper systems, care homes will come to see electronic systems in the same way. The main beneficiary from this will be the residents in terms of improved safety.

This, in turn, will benefit care home staff who will no longer be involved in the risky business of sorting out, transcribing and chasing paper records. Care home providers will also benefit through decreased indirect costs associated with more efficient and safer processes.

Reference: Alldred P, Barber N, Buckle P et al (2009) Care home use of medicines study (CHUMS): Medication errors in nursing and residential care homes – prevalence, consequences, causes, and solutions. Report to the Patient Safety Research Portfolio. Department of Health, London.

Steve Turner is Information Governance Lead and Data Protection Officer
for CareMeds Ltd

Author: Steve Turner

Date: 22.10.2019

Multi-morbidity & polypharmacy (taking 4 or more meds.)

May 15, 2017 By Steve Turner

Multi-morbidity and polypharmacy (that’s taking four or more medicines)

Taken from NICE Key Therapeutic Topics pages 5-10.

Key points:

People with multiple illnesses are often prescribed multiple medicines, with new medicines being added to counter side-effects of others. The actual benefits of doing this are hard to ascertain.

Taking multiple medicines involves increased risks.

Everyone with multiple illnesses should receive a holistic person-centred review of their medicines and share in the decision making of what they take. (My view takes this further. I’d say ‘be given the option to lead on the decision making of what they take’).

Polypharmacy (taking four or more medicines) can be divided into two categories. Appropriate polypharmacy, where the benefits and disadvantages have been fully evaluated together. Problematic polypharmacy, where this hasn’t been done and the benefits of the medicines are not realised, sometimes to the extent that they are making the person worse.

There are some useful tools which can be used to help evaluate appropriateness of medicines in individuals (described in the document). Additionally I’d add that motivational interviewing techniques and time to build trust of the patients are also vital.

Intentional non-adherence can be overcome in a trusting clinician patient relationship, which usually happens over time.

#jargonbuster ‘intentional non-adherence’ = not telling clinical staff what you are actually taking and/or not taking.

More on the NICE Key Therapeutics Document here:

Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed; MIHM

Steve is a nurse prescriber and NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @SteveMedGov

Steve is an Ambassador for @MedicineGov

Posting on #mentalhealth #MedsOpt #MedLearn #NICEGuidance #PatientEducation #substancemisuse #selfcare #prescribing

Search under #MedLearn

LinkedIn profile here: https://www.linkedin.com/in/sjturner/

For more on Care Right Now’s Patient Led Clinical Education work-streams click here: http://www.carerightnow.co.uk/projects/

‘Phone 01872 248327

Or email steve@carerightnow.co.uk

For part one of this blog ‘Medicines are overused’ click on the image below:

Meds Information UK

February 22, 2016 By Steve Turner

Some sources of information on medicines

This resource page is to help you to find helpful information on diagnosis, treatments and the medicines that you are prescribed, from trusted sources. (Don’t forget your health practitioner and Pharmacist will be able to recommend information, particularly for specific conditions such as diabetes or asthma). This is a guide only, not a definitive list.

patient.co.uk (symptom checker)	Electronic Medicines Compendium
Medicines for Children	Head Meds (mental helath medication)
Choice and Medication (mental health) to access this in your area see below.	NHS App

You can also download the British National Formulary [BNF] App for free:

Google play link: https://play.google.com/store/apps/details?id=com.pharmpress.bnf&hl=en_GB

iTunes link: https://itunes.apple.com/gb/app/bnf-publications/id1045514038?mt=8

Some notes on these links:

*Choice and medication (mental health medicines) Really helpful information on mental health medicines. Used by doctors and patients. Trusts who have signed up to this are listed on the right hand side. Usually their web site will give you the link, Click here for the Cornwall Link. Click here for the Lanarkshire Link (Scotland)

Electronic medicines compendium Look for the Patient information leaflets [PILs], they give you an idea how common the side effects are.

Other useful sites:

NAM aidsmap ‘HIV & AIDS sharing knowledge changing lives’

Want to keep a record of all your medicines?

My Medication Passport

Author: Steve Turner Head of Medicines & Prescribing @MedicineGov

Steve tweets as @MedicineGovSte

Last updated: 15.08.2019

External content:

This page includes external websites. We do not link to external sites in return for cash, services or any other consideration in kind.

These links are being provided as a convenience and for informational purposes only. The author bears no responsibility for the accuracy, legality or content of the external site or for that of subsequent links. Contact the external site for answers to questions regarding its content.

Children’s medicines – how listening to parents led to safer care

August 22, 2015 By Steve Turner

Case Study:

Background:
From 2008 to 2014 my company ran education sessions on managing medicines in a mental health trust. In common with some other mental health trusts the provider also looked after paediatric community services. This is not a mental health service. It covers children with complex health needs including enteral feeding tubes, ventilation; epilepsy and rapidly changing medicines. Children under the care of this service may be taking in excess of 15 different medicines per day, have complex titration regimes, emergency drugs with associated care plans, plus numerous ‘as required’ (prn) medicines.
It is not unusual for children with complex conditions to be under the care of up to five different providers, and to move between three different providers in one day. For example, from a Home Care Service to the Special School, to a Short Break House, maybe also being seen in an Outpatient Clinic on the same day too. As a result parents frequently have to repeat the information on their child’s medicines every time they move to another service, or a new person is involved.

Where to start?
The idea for change came about because of concerns that the staff in Children’s Short Break Houses were not learning what they needed about children’s medicines, as the learning was geared to the majority of staff who worked in mental health. So a new learning package for children’s staff was commissioned.
Part of the work to design the learning package included a baseline assessment which was conducted with parents and staff. This soon revealed that training alone was not the answer. It showed delays in medicines information reaching GPs, workarounds for obtaining information in order to administer medicines in the houses and a general lack of confidence in the whole process.
As a result we looked at the whole system starting with the area where most concerns had been raised, which was having an up to date complete list of a child’s medicines available at all times (medicines reconciliation). The system in place for Short Break Houses involved paying a local GP (not usually from the child’s GP Practice) to write up a medicines chart for each child. The process was fraught with difficulties and delays and widely disliked by everyone directly involved.
So we set about looking for a new way to manage the lists of medicines with more training and more input for the staff in the services involved. We came up with a new (and much more robust) process for medicines reconciliation in the Short Break Houses. This was fully documented in a new policy, and involved cross checking by both the staff and the parents.
Just before this went live, we asked the parents to review and comment on it and they said
‘If you’re producing an accurate and up-to-date list of my child’s medicines, why keep it the Short Break House, can’t it go with my child?’
So the My Medicines chart, which travels with the child, was born.

What was involved?
The My Medicines process led to the design and production of a new chart which has to be signed and checked by the parents.
It resulted in 40 children with complex conditions being offered a hand held paper record of their medicines (produced and validated by clinicians), which they take around with them wherever they go.

Benefits:
The new process, which continues to evolve, means that the child’s GP is now directly involved in day to day medicines reconciliation (they weren’t before); the parents are always asked to check and sign the charts (they weren’t before); verbal messages about medicines are never taken, and incomplete (or missing) directions are rapidly rectified (never worked around).
Some specific benefits of the new process include:
• It has reduced the risks of error, by providing full and accurate information on children’s medicine across their entire pathway.
• It cuts out the need for parents to keep having to repeat what medicines their child is taking to different professionals and care agencies.
• It frees up medical and clinical time which was previously spent chasing missing information.
• It has reduced the number of third part handovers and transcribing of prescription information.
Looking back it’s hard to believe that the old ways of working, which caused so many difficulties (especially for front line staff), were carried out for so long. These risky practices, or similar, are believed to still be commonplace in England.

Revealing hidden incidents and near misses:

In the first month of the project we raised 17 medicines or near misses. Of these 11 related to problems with communication of information across the child’s pathway.
Resolving these has resulted in improved communication and engagement between different clinical groups and providers, and a desire from all quarters to take the project further. Previously many of these incidents were not logged or tracked across organisations. In some cases it was only due to the vigilance of the staff and parents that they were spotted and errors avoided.

Accepting the changes:

The project was well received by parents and staff, and resulted in improved communication and engagement between different clinical groups and providers. This included the Consultant Paediatricians (working for the secondary care provider), who were initially sceptical.
The project was less well received by the relevant medicines and prescribing committees, who were understandably concerned about who owned the My Medicines chart and had agreed its content. Explaining this was made more difficult because it is hard to get across the complexity of the arrangements, due to the critical nature of the children’s illnesses, in a committee setting.
I make no apologies for ensuring from the outset that it was the parents who owned the charts, which were designed by the project team (not a committee) to meet all best practice standards. It always worries me that when it comes to cross- organisational working the formal committees and systems in place can inadvertently act as a barrier to safety rather than promoting it. There is no doubt we had designed a safer process and my company was happy to take accountability for any associated risks.
As a legacy of the project, a Community Paediatric Pharmacist was appointed specifically to work with this group of children. So whatever evolves will now be based on inter-disciplinary thinking and working and will have clear safety parameters. I am grateful to the enlightened thinking of the leaders who commissioned this work and supported this novel approach.

Steve Turner

Managing Director Care Right Now (CIC)

This example is incuded in the NICE Shared Learning resource and was highly commended in 2015.

Click here for the poster.