COMMUNITY REHABILITATION UNITS (ABERDEEN PARK AND HIGHVIEW)

MEDICINES MANAGEMENT PROCEDURE FEBRUARY 2019

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Policy title Community Rehabilitation Units’ Medicines Management Procedure

Policy reference MP12

Policy category Clinical

Relevant to Staff in Community Rehab units

Date published February 2019

Implementation date February 2019

Date last reviewed N/A

Next review date February 2021

Policy lead Lucy Reeves, Chief Pharmacist

Contact details Email: lucy.reeves@candi.nhs.uk Telephone:

Accountable director Vincent Kirchner, Medical Director

Approved by:

Lucy Reeves, Chief Pharmacist Joan Bradford, Service Manager

Document history Date Version Summary of amendments

April 2015 1 New SOP

Feb 2019 2 Routine review

Membership of the policy development/ review team

Audrey Coker, Lead Pharmacist for Clinical Services Simon Peel Lead Nurse for Medicines Management Beverley Boateng Clinical pharmacist, Joan Bradford, Paul Critchley, Rebecca Berrell

Consultation

Rehabilitation houses managers

DO NOT AMEND THIS DOCUMENT

Further copies of this document can be found on the Foundation Trust intranet.

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Contents Page

1 Introduction 1

2 Aims 1

3 Scope of the policy 1

4 Duties and responsibilities 2

5 General Principles 2

6 Admission 2

7 Prescribing 5

8 Administration and Documentation 5

9 Ordering and receiving medicines 6

10 Clozapine 8

11 Controlled Drugs 8

12 Security and Storage of medicines 9

13 Lost/missing keys 9

14 Disposal of medicines 9

15 Pharmacy service 10

16 Dissemination and implementation arrangements 11

17 Training requirements 11

18 Monitoring and audit arrangements 11

19 Audits 11

20 Review of the policy 12

21 Associated documents 12

Appendix 1: Medicines management audit criteria 13

Appendix 2: Record for patient filling dosette box finger 14

Appendix 3: Equality impact assessment 15

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1 Introduction

Camden & Islington Foundation Trust Supported Housing Schemes provide a Rehabilitation and Recovery service to residents with severe and enduring mental health problems referred via the Community Rehabilitation Teams. Residents are referred to 24 hour Community Rehabilitation Units. Admissions to the scheme are always pre-planned.

Location of Community Rehab Units:

19 Aberdeen Park

Highview Residential and Rehabilitation Services

The community rehabilitation units are staffed by a multidisciplinary team including medical,

nursing, psychology, occupational therapy and clinical support workers. Medical support is

provided jointly by the service user’s GP and the Community Rehabilitation Team

Psychiatrist.

2 Aims

To set out clear guidance and procedures to managers and staff for the management of medicines.

To ensure consistent and high standards of practice across supported housing schemes.

To ensure safe working practices in the ordering, storage, prescribing, administration and disposal of medicines.

To minimise risks and ensure the safety of service users and staff.

3 Scope of the policy

This procedure applies to all clinical support workers and mental health practitioners

involved in any stage of handling and administration of medicines within the community

rehabilitation units.

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4 Duties and responsibilities

4.1 The Team Manager has overall responsibility for ensuring staff receive the necessary training and adhere to the procedures in this document. This includes regular monitoring of practice and ensuring any incidents are reported and managed appropriately. To ensure competency, managers must ensure staff receive medicines management training.

4.2 Clinical support workers and mental health practitioners are responsible for following these procedures and ensuring their knowledge and competencies are kept up to date and any incidents are reported promptly using the approved process.

4.3 Junior doctors are responsible for writing the medicines administration records (MAR) for the service users using appropriate and up-to-date information. In emergencies, two members of staff who have undertaken and passed the medicines management accreditation course or undertaken the medicines management competency framework can write up the MAR charts. A copy of a MAR chart can be obtained from the trust self-administration of medication policy.

4.4 The delegated pharmacist will visit the unit every three months to provide a clinical pharmacy service and to check for the correct implementation of key medicines management principles.

5 General principles

On admission, service users are expected to have their own medication for self –administration obtained via their community pharmacy or hospital TTA. Service users will be assessed for self-administration in accordance with the Self-medication policye (Titled: Self-administration of medication (SAM) policy) located on the trust intranet. Some service users discharged from the wards may be on self-administration and this should be continued on admission to the rehabilitation unit.

6 Admission

6.1 The medication brought in by the resident must be checked against the GP summary if the patient is admitted from the Community or a discharge summary/discharge notification form if resident is transferred from hospital (level 1 - medicines reconciliation). The GP patient summary can be obtained via the summary care records (SCR). Patient consent must be obtained before accessing their information. Alternative electronic sources are MIG (Medical Interoperability Gateway and CIDR (Camden Integrated Digital Record). A copy of the GP medication summary must be saved in the resident’s Carenotes record for reference. At least two sources of

information must be used when ascertaining current medicines taken by patients.

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6.2 As part of the level 1 medicines reconciliation, staff admitting the service user to the unit must ascertain whether the service user uses any herbal or over the counter ) (OTC) medicines.

6.3 Staff must refer to the trust medicines reconciliation procedure located on the intranet.

6.4 Within the unit there will be members of staff who are responsible for the following:

Ensuring the name on the dispensed label corresponds to the resident.

Ensuring the medication is correct and corresponds to the GP summary/ discharge summary.

Ensuring the medication in the container corresponds to the label.

Ensuring that the expiry date is checked and if medication is not in date it must be removed with the consent of the service user.

Ensuring there is sufficient medication for the resident. If further supplies are required, the GP must be notified and a prescription obtained, to be dispensed from the community pharmacy.

Ensuring the Medicines Administration Record (MAR) Chart is completed by the junior doctors (Aberdeen Park and Highview).

6.5 The MAR chart must be filled in completely by the junior doctor to include the following:

Name of Community Rehab Unit

Name of the patient

DOB

Allergy Status*

Medicine name

Medicine strength e.g. 10mg, 15mg

Medicine form e.g. tablet, liquid, creams. patches

Medicine dose e.g. (1g = 2 x 500mg for paracetamol)

Medicine frequency e.g. once a day, twice a day, three times a day (no

abbreviations i.e. BD, TDS etc.)

Route e.g. oral, topical

Total quantity of medication received

A copy of the trust MAR chart can be obtained from the trust self-administration of medicines

(SAM) policy.

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6.6 In emergencies, two members of staff who have undertaken and passed the trust medicines management accreditation course or completed the medicines management competency framework can transcribe and check the entry of a new medicine on a MAR chart. The two members of staff must sign the entries made.

6.7 *Any concerns with the resident’s allergy status and medicine prescribed must be immediately raised with the junior doctor, GP or pharmacist. The medicine must be withheld until confirmed by the GP or pharmacist that it is safe to administer.

6.8 Following completion of the above checks, all medication must be locked in designated medicines cupboard/refrigerators or individual service users’ medication lockers.

6.9 All residents self-administer their medication, supervised by a staff member following the Trust Self-Administration procedure.

6.10 Only medicines prescribed for the individual resident may be taken by that resident.

6.11 Any OTC medicine bought by the resident must not be administered until the junior doctor has assessed the medicine for appropriateness and prescribed on the MAR chart. If this occurs on the weekend, this should be postponed until the doctor is available.

6.12 Medicines must be taken by the resident in accordance with the prescription and as documented on the MAR chart.

6.13 The staff member must sign the MAR chart to indicate supervised self-administration and that administration has been observed, if self-administration has not been achieved the MAR chart must be coded accordingly). This must be done immediately after self-administration of each medicine.

6.14 If the medicine is not taken due to refusal, wastage or lack of availability, the reason code must be recorded on the MAR chart and the non-adherence recorded in the residents’ notes. Where a service-user refuses to take their medicines then the House Manager, deputy and Care Coordinator must be informed and advice sought. If the medicine is not available then this must be followed up immediately with the dispensing pharmacy and GP as appropriate. Concordance forms can be obtained from the trust self-administration of medication policy.

6.15 MAR charts found to have blank administration boxes must be investigated and reported as an incident through the trust incident reporting system. Particular attention must be paid to high-risk medicines (such as anticoagulants, insulin, phenytoin, warfarin, clozapine etc.). If a dose of a high risk medicine is missed, medical staff must be informed.

6.16 The expiry dates of all medicines must be checked on admission. Medicines must not be administered after the expiry date and must be disposed of. Certain preparations have limited expiry dates once the preparations have been opened. In this instance, the date the preparations are opened should be documented on the packaging and new expiry date stickers must be attached.

6.17 When as required (PRN) medicines must be prescribed and self- administered as directed on the prescription (MAR chart and label).

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6.18 The ‘when as required prescription’ must indicate the dose, frequency interval and maximum dose in 24 hours.

6.19 Where a variable PRN dose is prescribed, then the dose that has been self- administered must be recorded on the MAR chart each time.

6.20 Self-administration and effectiveness of PRN medicines must be routinely monitored and reviewed. When PRN medicines are repeatedly requested, the GP must be notified and a medication review requested. Where PRN medicines are not/or infrequently being requested by the service user then the prescriptions must be cancelled or quantity adjusted to prevent supplies accumulating and wastage. The staff member opening the preparations must clearly and indelibly write the dates of opening and dates of expiry.

7 Prescribing

7.1 All medicines are prescribed using FP10 prescription forms by the resident’s GP, with the exception of clozapine which is prescribed by the Consultant Psychiatrist using the trust clozapine repeat prescription. The patient may be prescribed medicines from other specialist services e.g. anti-retroviral medicines. The house must confirm with the specialist service how these medicines should be obtained i.e. via the GP or the specialist service.

7.2 All medicines must be recorded on the MAR chart for individual named residents by the junior doctor.

7.3 Only prescribed medicines must be self- administered by residents.

7.4 Medicines are dispensed by the designated community pharmacy.

7.5 The GP will provide prescriptions for 28 day supply of medicines for each individual resident on a regular schedule, unless the medicine is an acute need or for specified course of time e.g. antibiotics. Prescriptions are sent directly to the community pharmacy for dispensing.

7.6 New medicines or changes to current medicine regime must be self-administered by the patient in accordance with the new prescription/treatment plan. If the medicine is for continuation then sufficient quantity must be obtained until the next scheduled supply in order for the quantities to align.

7.7 If any changes to current medicines are made, for example dose adjustment, change in formulation a new prescription must be written and dispensed with the correct dose/formulation and administration instructions on the label. The MAR chart must be amended accordingly. If medication is in a blister pack, then a prescription for all the regular medicines will be required from the GP surgery. The old supply must be returned to the Community Pharmacy. In the case of clozapine, this can be returned to the Trust Pharmacy.

8 Administration and Documentation

8.1 All residents must have a medication risk assessment completed by the team for self- administration using the Trust Self-Administration procedure and regularly reviewed. Residents will self-administer their medication based on the determined level of competence, i.e. level 1-3. The stage of self–administration must be documented on the MAR chart. The staff on duty are responsible for supervising self-administration

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which must be documented on the MAR chart. Level 1 requires a staff member to dispense and administer the medication for the resident. For each self – administration supervised the following must be recorded:

Time

Initials of staff

Number of tablets (i.e. if they take one or two)

8.2 The following codes are used for recording the administration:

Initials =Supervised by staff

D= Declined (service user declined medication)

O= Omission (must also be documented on Carenotes)

SA= Self-administration

N= Not available

F= Any other reason (detail to be recorded in Carenotes)

8.3 Medication which has been discontinued must be crossed through on both the medicine detail and administration record sections on the MAR chart. This must be initialled by two members of staff on duty. A written record (e.g. email) must be obtained from the prescriber to verify the discontinuation of medicines. This must be filed in the patient’s notes and an entry made in the Carenotes.

8.4 Residents on depot medication will continue to receive these from the community depot clinics or their GP surgeries. The due date of the depot medication and the date the resident received the depot must be recorded on the MAR chart.

8.5 Refusal and covert administration: If consent for administration is not given by a resident then staff must not deceive them into accepting medication (covert administration). It is essential that a distinction is made between those service users who have capacity to refuse medication and those who lack capacity to consent to treatment.

8.6 When a service user refuses to take their medicines on a continual basis then the reasons for refusal must be investigated. The GP and junior doctor must be informed and advice sought.

8.7 If a resident takes too much of their prescribed medication, then the prescriber or pharmacist (contact the on-call pharmacist if the incident is out of normal working hours) must be contacted immediately for advice. If unable to contact either, then the resident must be sent to A&E. A datix incident form must also be completed.

9 Ordering and receiving medicines

9.1 The GP practice will issue the prescriptions and send to the designated community pharmacy. Exceptions apply to the supply of clozapine( see section 10) and depot antipsychotic medication which may be administered via the community teams. The patient may be prescribed medicines from other specialist services e.g. anti-retroviral medicines. The house must confirm with the specialist service how these medicines should be obtained i.e. via the GP or the specialist service.

9.2 The community pharmacy will deliver the medicines to the team monthly or the resident will collect from the pharmacy. However, if there are changes to the

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medication either staff or resident will collect the prescription from the GP. All medicines must be dispensed for individual residents in original packaging or suitable container (e.g. blister packs) and labelled with directions for use. The staff member must check the medication received against the Medicines Administration Record (MAR) chart and FP10 prescription counterfoil (sent with dispensed medicines by community pharmacy) for accuracy. The FP10 counterfoil must be filed in the service users notes for reference.

9.3 If the documentation is correct, a record of the check must be made. The staff member must sign and date the MAR chart indicating that the chart and the medicines received have been checked and are correct. The quantities received must also be entered on the MAR chart.

9.4 Any discrepancies must be documented and immediately addressed with the community pharmacy and/or GP as appropriate. Medicines must not be self-administered by the resident until the discrepancy has been checked and appropriate correction made.

9.5 The House Managers are also responsible for monitoring any accumulation in supplies, for example repeat prescribing of PRN medicines in quantities greater than actually required. The GP must be notified and requested to review the prescription.

9.6 For new, discontinued or change in dosage - Interim prescriptions:

If the staff member considers there is need for a patient to be reviewed by the GP in between the scheduled visits then an appointment must be made with the GP or a referral to the Consultant Psychiatrist. If an FP10 prescription is issued with new medicines, the process outlined in section 7.6-7.7 must be followed. If a medicine is to be discontinued following the review by the GP then a written record of this must be sent and saved in the resident’s records. Verbal orders for any changes to prescriptions (e.g. discontinuation, changes in dose, formulation or new medicines) must not be accepted. Trust doctors must record any actions directly in Carenotes.

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9.7 In residential houses, arrangements for patients away from the home are as follows: On occasion when the patient needs to take their medicines away from the home (i.e. for short term leave), the original dispensed supply should accompany the patient provided that it can be returned. If this cannot be assured, a prescription for the short-term leave period should be requested from the GP and presented to the Community Pharmacy for dispensing. If a dosette box is required, refer to the self-administration procedure. The filling of a dosette box must be undertaken by the patient with supervision from a nurse or clinical support worker. The process must be documented on the designated form (appendix 2).

10 Clozapine

10.1 The dose to be taken by the resident will be checked against the instructions as labelled on the boxes supplied to the resident by pharmacy and recorded on the MAR chart. A copy of the current clozapine out-patient repeat prescription must be filed in the residents notes. The copy must be made at the point of issue before being sent to pharmacy or alternatively can be obtained from the trust pharmacy.

10.2 Clozapine is dispensed by the trust pharmacy at Highgate Mental Health Centre (HMHC). Clozapine may only be dispensed and administered to patients with a valid blood test result (see the trust clozapine treatment guidelines on the intranet).

10.3 The patient should go to the clozapine clinic at HMHC for blood tests as per their scheduled appointment. Pharmacy at HMHC will supply the clozapine on receipt of a valid blood test result.

10.4 For more detailed information refer to trust clozapine treatment guidelines on the intranet .

11 Controlled Drugs (CDs)

11.1 Refer to Trust Controlled Drug policy on the intranet for detailed information on storage, handling and record keeping for controlled drugs.

11.2 Only staff with the appropriate training should be involved with the handling of controlled drugs.

11.3 The trust CD policy and procedures on the intranet must be followed.

11.4 Two members of staff are required to record in the CD record book when receiving or supervising self- administration of controlled drugs.

11.5 Destruction of CDs must be carried out on site using the appropriate D.O.O.P kit which is then placed in the blue medicine waste bin. Destruction of individual patient dispensed controlled drugs may only be done by the trust pharmacist visiting the service and must be witnessed by the team manager or nurse. A record of the destruction must be made in the record book and signed by both members of staff.

11.6 All entries should be dated, signed, timed and witnessed and the balance should be checked at each administration.

11.7 There must be evidence to show that the controlled drug balance is checked on a weekly basis by the team manager and nurse as per trust policy. Pharmacists will carry out quarterly CD audits.

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12 Security and Storage of medicines

12.1 Detailed information on the requirements for the safe and secure storage of medicines is listed in the trust medicines management policy and must be followed.

12.2 Medicines must be stored in locked medicines cupboards in the clinic room except residents on stage 3 self-administration. In this case, medicines will be stored in a locked medicines cabinet in the resident’s room.

12.3 Medicines requiring refrigeration (marked ‘store in fridge’ or ‘store between 2° C - 8°C’) must be stored in a locked refrigerator used only for the storage of medicines. The temperature must be kept between 2°C - 8°C and checked every day using a digital maximum/minimum thermometer. The minimum, maximum and current temperature must be recorded on the trust refrigerator monitoring form (see the trust medicines management policy). If the reading falls outside this range, the advice on the refrigerator temperature monitoring form must be followed. The trust pharmacy must be contacted for advice regarding the further use of the medicines stored within. Any medicines stored in the refrigerator should be transferred immediately to another refrigerator. These medicines must be quarantined (i.e. separated from other medicines and clearly marked ‘not for use’) until pharmacy have advised if further use is appropriate or disposal necessary.

12.4 The room temperature must be monitored and documented on a daily basis on the trust room temperature recording form. If the temperature exceeds the recommended temperature (</= 25. C) the advice on the form must be followed and the trust pharmacy must be contacted.

12.5 Keys for the medicines room, medicine cupboards, medicines refrigerator and controlled drugs cupboard must be held by the staff member in charge and kept separately from non-medicine related keys. The controlled drug cupboard keys should be separate from the other medicine cupboard keys. If there are no CDs present, the keys can be kept together. Medicine keys must be handed over to the staff member in charge at each shift change.

13 Lost/missing keys

13.1 Every attempt should be made to avoid the loss of medication keys, the necessary steps are highlighted in the trust medicines management policy.

13.2 In an emergency, spare medication keys can be found as follows:

Aberdeen Park: The spare keys are kept in secure storage at Highview.

Highview: The spare keys are kept in secure storage at Aberdeen Park.

14 Disposal of medicines

14.1 Detailed information on the requirements for disposal of medicines is listed in the Trust Medicines Management policy.

14.2 All medicines (except controlled drugs and cytotoxic medicines) date expired or no longer suitable for use should be discarded into a blue pharmaceutical waste bin in their original container or packaging.

14.3 Medicines prepared ready for administration, or removed from the original container, but not used must be disposed of in yellow pharmaceutical waste bins. If the

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medicine contains sharps (i.e. open ampoules), it must be discarded in a yellow pharmaceutical waste bin.

14.4 Cytotoxic/cytostatic medicines must be disposed of separately to other medicines in a purple lidded container. Trust pharmacy should be should be contacted for further information in the event of such medicines being used in the service.

14.5 Controlled Drugs that have expired, no longer fit for use, or no longer required on the unit, must be destroyed using a denaturing kit (DOOP) with a trust pharmacist. The used denaturing kit must be stored in the CD cupboard before disposing of in blue medicines waste bins. See section 11 for more detail.

15 Pharmacy service

15.1 The pharmacist will visit approximately once every three months to provide a clinical pharmacy service, including review of prescribed medicines and MAR charts, and to monitor the safe and secure handling of medicines. The pharmacist is also available to provide medicines information advice, support and training for staff and counselling to residents as required.

Highgate Mental Health Centre opening hours are 9.00am – 5.15pm Monday-Friday

and Saturday 10am-1pm.

The On-Call pharmacist may be contacted outside these hours via Whittington

hospital switchboard for urgent/emergency advice.

16 Dissemination and implementation arrangements

16.1 This document will be circulated to all staff within the team, involved in the handling of medicines. It will be available to all staff via Trust intranet. Managers must ensure that all staff are briefed on its contents and understand what it means for their practice, as part of their responsibility.

17 Training requirements

17.1 All staff must successfully complete the local induction period of supervision and complete a course in medicines management

17.2 The manager has responsibility to use the competency assessment tool to assess clinical support workers and maintain all records.

18 Monitoring and audit arrangements

18.1 Compliance with this Medicines Management procedure will be monitored monthly by the Team manager or deputy. Criteria to be monitored are listed in appendix 1.

18.2 Safe & secure handling of medicines and controlled drugs will be audited through the Trust Medicines Management annual audit programme.

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19 Audits

Elements to be

monitored

Lead How trust will monitor compliance

Frequency Reporting arrangements Which committee or group will the monitoring report go to?

Acting on recommendations and Lead(s) Which committee or group will act on recommendations?

Change in practice and lessons to be shared How will changes be implemented and lessons learnt/ shared?

Handwritten entries on MAR, signed by two support workers

Team manager

Audit Monthly Operational Management

Meeting

(O M M)

Monthly

Suggested wording

Required actions will be identified and completed in a specified timeframe

Suggested wording

Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders

Blank spaces on MAR

https://www.oc-meridian.com/candi/completion/custom/default.aspx?slid=167&did=

Team manager

Audit Monthly As above

Dispensed medication are checked against the MAR chart and original GP summary/clozapine outpatient prescription

Team manager

Audit Monthly As above

Controlled Drugs Pharmacist Audit Quarterly DTC

Safe & secure handling of medicines

Pharmacist Audit Annually DTC

Safe and secure handling of medicines: Medication Audit Weekly

Team Manager

Audit Monthly

20.0 Review of the policy

Two years, February 2021

21.0 Associated documents

Trust Medicines Management Policy

Trust Controlled Drug Policy

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Trust Controlled Drug Standard Operating Procedure (SOP)

Trust Covert Administration of Medicines Policy.

Trust Self administration procedure

Appendix 1 Medicines Management Audit Criteria These criteria should be checked monthly by the manager or deputy. Results of the audit checks will be monitored by the team manager. Required actions will be identified and completed in a specified timeframe.

a) Dispensed medicines and MAR checked against FP10 counterfoil / clozapine chart. Each medicine has been signed and dated as checked by designated staff member. Where medicines are not signed as having been checked there is a documented reason and action taken.

b) Any hand written entries on MAR chart are signed and dated by two designated staff

members on shift.

c) Medicines administration is recorded or reason for not administering (by code) on the MAR. There are no blank spaces on at due times for administration.

d) Number of medicine units (i.e. tablets/capsules) remaining reconciles with records of

administration. Where there is a discrepancy the reason has been documented and action taken.

e) PRN medicines have been administered in accordance with prescription. Where

being given regularly the GP has been requested to review.

f) Controlled Drug balance in stock and record book correct. All entries in controlled drug record book in accordance with standards set out in Trust Controlled Drug Standard Operating Procedure.

g) Where necessary the date of opening has been written on the label of the medicine.

The ‘do not use by date’ is also clear.

h) All medicines being administered are in date.

i) All medicines are stored appropriately in locked medicines cupboard, CD cupboard or medicines fridge.

j) Fridge temperature is monitored daily and appropriate action taken where

temperature has deviated outside 2-8 degrees C

k) Rooms where medicines are stored are temperature monitored daily and appropriate action taken where temperature has deviated above 25 degrees C.

l) There is an up to date log of all disposed medicines.

m) The meridian audit in the audit tablet must be completed.

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Appendix 2: Record for patient filling dosette box finger

Patient Name: Age:

Ward/Service: Care Notes No.

Medicine Medicine chart checked by a nurse of a clinical practitioner (signature)

Medicine added correctly to the dosette finger by patient. Checked by nurse or clinical practitioner (signature)

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Appendix 3

Equality Impact Assessment Tool

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race N0

Ethnic origins (including gypsies and travellers) N0

Nationality N0

Gender N0

Culture N0

Religion or belief N0

Sexual orientation including lesbian, gay and bisexual people

N0

Age N0

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

N0

2. Is there any evidence that some groups are affected differently?

N0

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance likely to be negative?

N/A

5. If so can the impact be avoided? N/A

6. What alternatives are there to achieving the policy/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action?

N/A