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Clinical Governance in Medicines Management & prescribing in
hospitalswww.allaboutpharmacy.co.uk
Dr Jonathan CookeSouth Manchester University
Hospitals NHS Trust Manchester January 30th 2003
jonathan.cooke@man.ac.uk
Professional self regulation
Clinical Governance
Lifelong learning
Setting, delivering, monitoring standards
National Institute for Clinical Excellence
National Service Frameworks
Commission for Health Improvement
National Performance Framework
National Patient and User Survey
StrategicHealth
Authorities
PrimaryCare
Organisations
LocalAuthorities
NHS HospitalTrusts
NHSExecutive
RegionalOffices
key
HIP
statuary a/cservice a/c NICE
CHAI
Pharmacy in the Future – Implementing the NHS Plan
Clinical pharmacy MAU pharmacists Patients own medicines Self administration Pharmacist prescribing HSC(2000)026 Concordance
Pharmacy in the Future – Implementing the NHS Plan
Medicines Management Skill mix and Automation -
– – dispensing, aseptics, procurement
Education and Training, Manpower Research and development Electronic prescribing
Medicines Management Agenda in hospitals
Controls Assurance Standards
NHSE performance management of medicines management in NHS hospitals
Audit Commission - Audit of Medicines Management
Medicines Management Agenda in hospitals
Controls Assurance Standards
NHSE performance management of medicines management in NHS hospitals
Audit Commission - Audit of Medicines Management
The diagnostic audit
Relative change in expenditureon medicines in past 3 years
Overspend on medicines in
past 3 years
Vacancies
in pharmacy department
Throughput per staff member
Staff activity in pharmacy
department
Use of patients’ ownmedicines & self-administration
Use of original packs andmeans of prescribing
Development of joint formularybetween primary & acute care
Is there effective control overmedicines expenditure?
Is staffing adequate for theservices which should be
provided?
Is there effective use ofpharmacy staff?
Has the service introducedprocesses in line withaccepted good practice?
Are the data corroboratedby other central returns?
Key diagnostic questions
Judgement:In depth audit
work / No further audit work
In-depth audit: how it applies
DIAGNOSTIC AUDIT
Indicators of cost
Indicators of process
Indicators of staffing and workload intensity
Indicators of staff deployment
IN-DEPTH AUDIT
Surveys of user groups: nurses, doctors, consultants, managers, GPs, patients
Module 1: Management arrangements
Module 2: Financial control
Module 4: Procurement
Module 3: Policy and use
Module 5: Primary care interface
Module 6: Prescribing influence
Module 7: Risk management
A spoonful of sugarrecommendations (1)
1. The establishment of standard nation-wide definitions and categories of medication errors and ‘near-misses’ should be an early priority for the new National Patient Safety Agency.
2. Following agreement of standard definitions and categories of medication errors, base-line audits should be undertaken.
Building a Safer NHSSpecific risks targeted for
action Eliminate deaths/disability of the
maladministration of spinal inj - 2001 Reduce by 25% harmful incidences in
O/G -resulting in litigation - 2005 Reduce by 40% number of serious
errors in prescribed drugs - 2005 Reduction in suicides in MH patients
HIRSWeb form
encryption email
server
Access DB
reportsdecoding ACTION
South Manchester University Hospitals
Incident Reporting System
South ManchesterTypes of medication incidents reported %
n=320 since April 2001
0 10 20 30 40 50
Delivery error
Supply error
Prescription error
Admin. error
HIRS Medication errors %
0 10 20 30 40
Oral anticoag
Digoxin
Corticosteroids
NSAIDS
Amil/amlod
Paracetamol
Lignocaine
Penicillins
others
Insulins
Heparins
Opiates
Incident classification %
0 50
Medicine not available
Contraindicated drug
Significant underdose
Am biguous prescription
Excessive IV rate
Wrong drug prescribed
Dispensing error
Wrong m edicine given
Medicine overdose
A spoonful of sugarrecommendations (2)
3. National co-ordination of publicity posters should be considered to encourage patients to take their medicines into hospital with them
4. The DoH and the National Assembly need to work with HM Customs and Excise to equalise tax treatments between hospital and community sectors and thus remove what is becoming an obstacle to best prescribing practice
5. The DoH and the National Assembly should commission a specification for automated dispensary systems and consider the provision of earmarked funds to roll-out the introduction of these systems to all trusts
A spoonful of sugarrecommendations (3)
6. A standard national system for the coding of medicines and barcodes should be introduced across the whole of the NHS to support the development of electronic prescribing systems and automated dispensing systems
7. Earmarked funds should be made available to enable trusts to comply with the targets that are set in the NHS IM and T strategy. Central guidance on systems specification and screen layouts should be considered
8. Trusts’ medicines management framework returns should be analysed in conjunction with returns to the Audit Commission’s acute hospitals portfolio. The DoH and the National Assembly should consider using this exercise to enable the identification of Beacon Sites for medicines management.
A spoonful of sugarrecommendations (6)
13 Trust boards should use the DoH’s Medicines Management Framework in conjunction with the Audit Commission’s diagnostic to review medicines management arrangements and develop local action plans
14 Medicines formularies should be agreed that are linked to joint care arrangements, clinical guidelines and NICE guidance
15 Medicines management groups and DTCs should be made formally accountable to the trust board or to the clinical governance committee
16 Risk management arrangements should be reviewed and ‘fair blame’ and ‘near miss’ reporting systems introduced
SMUHT Medicines Management Committee
To develop and ratify the Trust policy for Medicines ManagementTo recommend and review procedures for the control, storage and administration of medicines (drugs and prescribable dressings)To receive and respond to applications for the use of new medicines from the Major Business Units
SMUHT Medicines Management Committee
To produce and maintain a Trust formularyTo ensure effective methods of promulgation of policy decisions to cliniciansTo liase with specialists and with PCOs and Area Prescribing Committees (APCs) to develop guidelines for the safe, effective and economic use of medicines To commission audits to ensure that policies and guidelines are implemented
How we deal with NICE guidance and the NSFs
NICE Technology appraisal - medicines
Clinical Governance Chairman
Medicines Management Chairman
Specialists
Medicines Management Committee
Formulary/Guidelines/PracticeHospital Care
NICE technology appraisals
46 obesity – surgery clinical audit 47 Giib/iiia inhibitors update MMC 48 haemodialysis home v hosp clinical audit 49 ultrasound for CVC clinical audit 50 imatinib CML MMC 51 depression, cognitive therapy clinical audit 52 myocardial infarction early Rx MMC 53 diabetes long acting insulin MMC 54 vinorelbine in breast CA Christie
A spoonful of sugarrecommendations (7)
17. Trust boards and senior managers should seek regular assurance that actual clinical practice reflects agreed protocols – in particular, the practice of making-up aseptic preparations on hospital wards should be stopped- CIVAs SERVICE - NPSA
18. Lead clinicians should ensure that the induction programme of all clinical staff provides adequate coverage of policies on prescribing practice, medicines administration and incident reporting. Monitoring of competencies in prescription and administration of medicines should be given high priority - Education and Training
19. Trusts should undertake reviews of pharmacy staffing levels and consider whether there are adequate resources to:(i) provide for all aspects of clinical pharmacy services;(ii) meet the demands of the NHS Plan in respect of new consultants and nurse prescribers; (iii) take patients’ medication histories; and(iv) support dispensing for discharge schemes
A spoonful of sugarrecommendations (8)
20. Arrangements should be introduced for the use of patients’ own medicines in hospital
21. Trust boards should call for a position statement on progress towards introducing self-administration of medicines and providing the necessary staff resource to maximise implementation
22. Original pack dispensing should be introduced in all appropriate areas immediately, using Department of Health guidance. Re-packaging of medicines from bulk should be stopped, wherever possible
23. The annual Service and Financial Framework round should include an assessment of future cost pressures from medicines, and a risk-sharing approach agreed between commissioners and providers
Cost pressures for 2003 and beyondinforming the LDP process
Gpiib/iiia inhibitors Taxanes Ribavarin & interferon
alpha anti TNF medicines
for Crohn’s & RA Glitazones Imatinib Insulin glargine
Syringes & minibags - EL(97)52
Antimicrobials HIV therapy LMW heparins Olizumab in asthma Tobramycin inhalation morphine syringes &
co-phenylcaine spray
% INCREASE IN OUTTURN EXPENDITURE BETWEEN 98/99 -00/01
% c
han
ge
98/9
9 -
00/0
1
South Manchester vs Teaching outside London
0
10
20
30
40
*
INTERFACE WITH PRIMARY CARES
core
(o
ut
of
27)
South Manchester vs Teaching outside London
0
5
10
15
20
25
*
The MANMED Survey Postal survey of medicines management in England MANMED (PCO) survey
– PCO prescribing priorities– high profile drugs– NSFs and NICE guidance– PCO prescribing initiatives
MANMED (NHST) Survey– NHS Trust expenditure– pharmacy IT facilities– NSFs and NICE guidance– Prescribing policies
The MANMED SurveyPattern of Response
MANMED (PCO) survey– 66% response rate (N=332)– representative of all PCOs in England
MANMED (NHST) survey– 57% response rate (N=275)– Representative of all NHSTs in England
Survey of chief pharmacists 2001
UK chief pharmacists surveyed in 2001 157/275 responses (57%) Mean trust expenditure £107m (SD £71m) Medicines expenditure £5.6m (SD £9.5m) 80% of budgets held in clinical divisions
Survey of chief pharmacists 2001IT facilities
Intranet 81% Internet 87% EDI 40% EDI invoice processing 13% Web site 37% Web formulary 21% Electronic prescribing 3% (11% partial)
DTC in 97% of hospitalsWho sits on DTC?
0102030405060708090
100
cons chief P hospP
nurse PCO GP Finman
GenMan
JunDoc
CEO patient
%
Survey of chief pharmacists 2001prescribing policies
Formulary – 78% New medicines scheme – 90% Impact on Primary Care – 94% Shared with Primary Care – 77%
Survey of chief pharmacists 2001new medicines introduction
Glitazones 79% Infliximab 70% Celecoxib 62% Linezolid 44% Esomeprazole 42% Zanamivir 34% Oxycodone 32%
Survey of chief pharmacists 2001Specific policies
28 day/OP/OP dispensing 67% 28 day/OP/1 stop dispensing 68% Reuse of Patients medicines 73% Self administration of meds 62% Nurse authorisation PGD 83% Pharmacist authorisation PGD 27%
Action on NICE guidance %ACTION PPIs Glits taxanes
Audit of practice 43 12 24 Committee set up 11 4 7 DTC submission 24 51 15 Rev of disease man guide 29 21 15 Identify indicators 10 5 8 Funding request 2 11 39 Guidance circulated 66 65 54 Directive issued 11 11 7 Formulary modified 31 44 13 No action 26 21 31
Action on NSFs %ACTION CHD Mental Health
Audit of practice vs NICE42 25 Committee set up 41 31 DTC submission 27 12 Rev of disease man guide 45 23 Identify indicators 18 8 Funding request 35 15 Guidance circulated 56 33 Directive issued 8 5 Formulary modified 20 7 No action 19 30
StrategicHealth
Authorities
PrimaryCare
Organisations
LocalAuthorities
NHS HospitalTrusts
NHSExecutive
RegionalOffices
key
HIP
statuary a/cservice a/c NICE
CHAI
Thank You
Any Questions?
MMC new medicines 2002 Medicine Approval
caspofungin limitedvoriconazole limitedzoledronic acid deferdetrusitol XL noelleste yes for GPsdovobet yesinsulin glargine yes
tiotropium yes
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