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Barnet CEPN
Prescribing Clerk Training
Session 3
Barnet
CEPNAims of the Training Programme
Aims: Aims of the Programme
Develop the existing role of prescription clerks in practices
Helping practices staff to improve workload management
To improve patient safety and experience
To develop IT skills to enhance uptake of electronic
systems to manage repeat prescribing process
Improving communication between practices, their patients
and the community pharmacists.
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CEPNWho we are
Group 1 ( Finchley Memorial/ Wednesdays
Joanna Yong: Barnet GP
Femeeda Padhani : Practice Based Pharmacist
Group 2 ( Edgware Hospital/ Thursdays)
Namrata Gandhi : Barnet GP
Saijal Ladd : CCG Pharmacist
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CEPNContact Information
Kyra Rowlatt – Barnet CEPN Non Clinical Lead
07951 822820 (for any urgent matters or queries)
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Sessions so far:
Session 1
Introduction
Getting to know you
Prescription journey
Common prescriptions
Session 2
Acutes vs repeats
Safe prescribing
Medicines wastage
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CEPNSo far…
Current roles and how you would like to improve
Legality of prescriptions
Commonly prescribed drugs
Acutes vs Repeats
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CEPNIntroduction and aims for session
Understand why medication reviews are important
Understand which medications commonly need regular
monitoring and why
Understand difficulties faced with communication in
your practices
Empower you to have confidence in dealing with
patient queries
Using role play as tool to enhance communication skills
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Programme- Session 3
09.30-09.45 Safe prescribing /competencies
09.45-10.40 Medication reviews & drugs that need regular
monitoring
10.40-11.00 Cases
Break 11.00- 11.15
11.00-11.10 Communication
11.10-12.10 Roles plays
12.10-12.30 Summary and Evaluation
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CEPNHelp support safe prescribing
Do you feel safe?
Improving your confidence, raise concerns
Ask questions! Phone a friend
Think about who do you ask? – Your prescribing lead, your community pharmacist, your practice based pharmacist, CCG pharmacist, practice nurse
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Are you working within your competencies?
Acute medication or medication not previously issued
If the review is overdue or medication requested early/very late (possible issues with compliance)
Any changes made by patient
When a review is overdue
Prioritise review in vulnerable patient groups. Patients at risk of medication related problems
Special needs
New diagnosis
Potential problems...
PRACTICALPrescription
‘gone missing’
Something ‘missed off’
Script gone to ‘wrong place
Sheer volume -hard to check when requests were actually
made by patient
Addicts -requests for
CDs etc.
Potential problems...
CLINICAL/
MANAGERIAL
Poor clinical control - need recall system
Staff not aware of consequences
Staff feel pressured to
‘help’ and ‘save Doctors time’
Helping the Doctor actually puts them at
risk
Staff obliged to look things up in MIMS/BNF -with inevitable
errors
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CEPNMedication reviews
For 15 minutes in your groups please discuss the way these are done in your practices. Then feedback to the group.
Things to consider
Does your practice have a policy for medication reviews?
How often are reviews updated?
Who carries out reviews?
What do you feel can be done better?
How are patients who do not respond to reminders managed?
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Feedback from group
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Why have a Medication Review System?
Why do Medication Reviews?
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Why have a medication review
system? A repeat is not for life!
Safety!
Avoid waste and save money
Clinical governance
Having a system provides guidance and structure to patients, staff and the clinician to ensure all the above are address at specified time intervals
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CEPNWhy do medication reviews?
To ensure that patients are properly monitored
Avoid drug induced illness.
Side effects of some medications need additional monitoring to detect
Ensure effectiveness of medication
Ensure stable on medication
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A definition of medication review is “a structured, critical
examination of a patient’s medicines with the objective
of reaching an agreement with the patient about
treatment, optimising the impact of medicines,
minimising the number of medication related problems
and reducing waste”. (Room for Review, 2002)1 The
review should, ideally be with the patient.
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How often should a medication review be
done?
Asthma
CHD
Mental health conditions
Diabetes
Hypertension
Epilepsy
Thyroid conditions
HRT
Contraception
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Medical Condition Test or check up How often
Heart conditions
High blood pressure , stroke or
other heart conditions
BP, height and weight, Blood test, Urine
protein test (in some cases)
Annual (minimum)
Diabetes Eye check (local clinic NOT at GP), Foot
check (GP practice nurse), BP, height and
weight, Blood test, Urine protein test
Stable – 6 monthly (minimum).
Not stable or levels not in
‘target’range – then more frequent
i.e. 3 monthly.
High cholesterol BP, height and weight
Blood test
Annual (minimum)
Stroke or mini stroke (TIA) BP, height and weight
Blood test
Urine protein test (in some cases if BP is
too high)
Annual
Peripheral arterial disease
i.e. narrowing of leg arteries
either due to blockage or
previous surgery (bypass of
arteries)
BP, height and weight
Blood test
Urine protein test (in some cases if BP is
too high)
Annual
Kidney disease
Stage 3,4 or 5 ONLY
BP, height and weight
Blood test
Urine protein test
Urine dipstick
Six monthly with GP or more
frequent as per hospital specialist
(as applicable).
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Thyroid Blood test (thyroid ) Annual
Mental Health condition requiring
medication (except depression)
Mental health condition not
requiring medication
ECG (in some cases)
BP, height and weight
Blood test
Specific drug levels (depending on which
medication you take)
No routine tests required.
Annual
Annual GP appointment face to face
*some medications or conditions
require more frequent follow up, you
will discuss this with your GP
prescriber or hospital specialist*
Annual GP follow up (minimum)
Rheumatoid Arthritis BP, height and weight
Blood test
Specific drug levels (depending on which
medication you take)
*Some may require eye test or chest xrays.
2-3 months
Annual GP appointment face to face
*some medications or conditions
require more or less frequent follow
up, you will discuss this with your GP
prescriber or hospital specialist *
Lung Conditions
Asthma and COPD
Inhaler check with practice nurse or clinical
pharmacist
Annual
Contraception tablets BP, height and weight 6 months + annual f2f appt
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CEPNDrugs which need regular monitoring?
Can you name some?
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Lithium
Warfarin INR (TTR)
NOACS (apixaban, rivaroxaban)
Carbimazole
Sodium valproate
Theophylline
Digoxin
Methotrexate weekly dose 1st 3months issued by hospital. Once stable then 3mthly blds FBC/ UE/ LFTs
Shared care guidance
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Why do some drugs need Frequent and
regular monitoring?
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CEPNNarrow Therapeutic Index
Some drugs have a narrow therapeutic index, which
means that there is only a small difference between the
minimum effective concentrations and the minimum
toxic concentrations in the blood. With such drugs,
small increases in dose or in blood/serum
concentrations could lead to toxic effects.
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CEPNWhat would you do?
Mr Smith puts in a request for warfarin but he has not
submitted an INR reading. You check the records and
note that the last INR was 4 months ago?
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CEPNWhat would you do …..
Mr Smith submits a request for warfarin along with a
recent INR reading done two days ago. The INR
reading is 7.
In his care history you note that the target INR is
between 2-3
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Methotrexate - wrong dose on repeat.
Patient died
Prescribing recommendations. Weekly dose
Amiodarone 200mg t.d.s. for 2 years - no monitoring,
not stepped down
Patient died.
Amlodipine 10mg b.d. for 2 years (‘ISTIN’ given instead
of ISMN)
Brand c.f. generic prescribing.
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Name 5 common long term conditions
Name 5 common vulnerable groups
Name 3 common situations where a persons
medication might change?
5 mins in different pair
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Feedback to the whole group
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Long term conditions
Cardiovascular – Heart disease
Diabetes
Respiratory – asthma, COPD
Hypothyroidism
Gastrointestinal – Crohn’s, IBD
Rheumatoid arthritis
Mental Health
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CEPNVulnerable
Prioritise review in vulnerable
patient groups.Patients at risk of medication
related problems
Special needs
New diagnosis
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Vulnerable groups
Elderly
Dosset boxes / MARS
Residential home patients - which are your local residential homes ?
Dementia
Housebound patients
polypharmacy More than 6 items on their repeats.
People with Mental health
Learning Disabilities
Others include:
Children with long term conditions/ special needs
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In what situation might a person’s
medication change ?
Answers
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New patients
Patients recently discharged from hospital
Significant illness
New diagnosis
Temporary patients should only really be issued acutes
CCG medication switches
Script switch
Side effects
Unavailability
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CEPNLight bite
Does any practice have a particularly good method
(if not can alter the Brunswick one and use as
example)
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CEPNBrunswick example
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CEPNBreak
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CEPNCommunication!
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CEPNWhy are we focusing on communication?
Dealing with difficult patients may not only benefit you
(honestly!) it will benefit the surgery as well;
Being confident at handling difficult patients is an asset
to the practice and a credit to you if done well. It will
help with your confidence when dealing with the next
difficult patient.
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CEPNCommunication skills
Who do you have to communicate with?
What are the different modes of communication?
Which modes of communication do you find the most
difficult and why?
What would make it easier?
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CEPNWho do you communicate with?
GPs
Pharmacists
Patients
Relatives of patients
Colleagues
Other organisations eg- hospital/ care homes
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CEPNModes of communication
Phone
Fax
Online requests
Screen messages
Hand written notes
Tasks
Face to face
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CEPNTelephone triage
Consider possible issues
Poor line
No cues from body language
May be doing a few things at once
What is suitable to be dealt with over the phone?
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CEPNAngry patient
How do you feel when dealing with an angry patient?
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CEPNAngry patient
Can leave you feeling tired, drained, not in control of
the situation
Often have other causes for their frustration
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CEPNCases
Urgent request for medication on Friday evening
Given shorter supply as not responded to med review
Rejected prescription request for medication on acute
Patient lost CD script and wants duplicate
Duty Dr running late and pharmacy query on the phone
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In groups of 3 or 4 act out the scenarios and give each other feedback
1 person as reception, 1 as GP/pt/pharmacist
Rest of the group to observe
Think about What went well?
At what point did the patient calm down?
Could anything be improved?
Following feedback – we will ask you to redo the role play for the group
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CEPNRole play
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Try not to get angry towards the patient (it can be hard)
Keep your voice calm even if they raise their voice
Try to find a workable and realistic solution
Sometimes patient may understand the reason for
delay – helpful if you can explain
Ask for help when needed (if you feel out of your depth)
Don’t take it personally
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CEPNSome helpful phrases….
“I’m so sorry that you feel this way, Mrs Brown…”
May I arrange for an update call, at a time most convenient for you?”
“I completely understand how you feel, Sir/Madam…”
“We really do appreciate this feedback, Mrs Brown…”
Let me see how I can fix this, Mrs Brown…”
“Thank you so much for your patience/understanding, Mrs Brown…”
I am so sorry you are so upset, would you like us to call you back when you are a little calmer?
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If people remain angry, it is often because they think that they are not being
listened to
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Feedback
Change in practice- name 3 things that will change
your practice.
Audit feedback
Evaluation forms
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CEPNNext session- 4
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Things to start thinking about
Who your local community pharmacists are
Making contact with them- introduce yourself
Planning dates for May/ June
For you to visit your local community pharmacy for 2 hrs
To arrange a time for a member of your local community
pharmacist to come into the surgery.
For the next session – identify which pharmacy you have
identified/ have contacted.
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CEPNFeedback
Feedback from learning - to date : Change in
practice ? Any thing you've done differently -
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CEPNFeedback
We really value your
feedback so please
return your evaluation
forms before you leave,
thank you!
