05/03/2014

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Nurse and Midwife Prescribing in Ireland: 

Have we Built a Culture of  Safety?

TIM DELANEY, HEAD OF PHARMACY, TALLAGHT HOSPITAL

DUBLIN CASTLETHURSDAY 27TH FEBRUARY 2014

Political History� 1998  Report of the Commission on Nursing: Blueprint for the 

Future (Government of Ireland).

� 2001  An Bord Altranais  & National Council for the Professional Development of Nursing and Midwifery project  Review of Nurses and Midwives in the Prescribing and Administration of Medicinal Products. 

� 2005  Final Report of this project made key recommendations    to support the expansion of practice of nurse and midwife prescribing.

� 2006 Irish Medicines Board (Miscellaneous Provisions)  Act contained an enabling provision for prescriptive authority for nurses and midwives. 

� 2007 Minister for Health and Children signed into law the medicines regulations providing the regulatory framework.

The Political Landscape 

� Financial and Emergency Provisions Legislation 2009‐10� Erosion of pharmacy  and GP payments 

� Salary reductions per  Haddington Road 

� Health (Pricing and Supply of Medical Goods) Bill 2012 � Reference pricing

� IMB lists of interchangeable medications

� Opportunities for automation

� EWTD and Doctors’ Hours� Need to explore alternative means of doing some NCHD work

� Prescribing?

� Financial Crisis � Hampering investment in technology

� Preventing recruitment

Political Landscape 

HIQA / Pharmaceutical Society of Ireland  (PSI)

� National Quality Standards for ResidentialCare for Older People 2009 

� PSI Circular  to pharmacists March 2010 

� HIQA National e‐Health Interoperability Standards for Ireland  published 2014 

Includes discharge prescription dataset

Drivers for Medication Safety (IHI)

1. Reliable Medication Management Processes 

in residential care settings (acute hospitals, 

mental health facilities, nursing homes, 

hospices, maternity hospitals).

2. Good Co‐ordination of Care at interfaces 

where care is transferred in the system.

3. Patient and family involvement in their own 

care.

Prescriber numbers now over 600 and growing steadily...

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2008 2009 2010 2011 2012 2013

Newly Registered Total Active Nurse Prescribers

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But more to do?

� As of 2013, 1% of all active registered nurses is a qualified prescriber (617 )

� These prescribers wrote  about 29,000 prescriptions in 2013, an average of 12 per quarter

� In 2011 there were 2,758 GP prescribers who wrote 18.7 million prescriptions, an average of 1,700 per quarter

� Nurse prescription volume is 0.15% of GP volume  although nurse prescriber numbers are 22% of GP numbers

Half of all Prescribers are in Eight Areas of Care

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 No Cumul%

8 Areas with greatest nurse prescriber presence

Clinical Area No Cumul%35 Emergency Department 121 12%

7 Care of the Older Person 104 23%

64 Midwifery 90 32%

55 Mental Health 72 39%

31 Diabetes 40 43%

51 Intellectual Disability 33 47%

88 Public Health Nursing 23 49%

70 Midwifery Labour Delivery 22 51%

Source : National Implementation Report on the Nurse and Midwife MedicinalProduct Prescribing Initiative From 1 October – 31 December 212

The other half are spread across 94 service areas 

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30%

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 No Cumul%

76% of all prescriptions are written in 8 clinical areas

Clinical Area Number of

Prescription Episodes

% Total Episodes

Emergency Department 2114 29%

Midwifery 832 11%

Ophthalmology 825 11%

Diabetes 660 9%

Care of the Older Person 445 6%

Midwifery Delivery 272 4%

Oncology 263 4%

Sexual Health 172 2%

Source : National Implementation Report on the Nurse and Midwife MedicinalProduct Prescribing Initiative From 1 October – 31 December 212

A few heavy prescribers but average rates are low

Clinical AreaNo. of

Prescribers

Number of Prescription

Episodes

Quarterly Episodes per

Prescriber

Ophthalmology 1 825 825

Children’s Intensive Care 1 163 163

Urodynamics 1 64 64

Smoking Cessation 1 36 36

Ear, Nose & Throat 1 25 25

Sexual Health 8 172 22

Colorectal 3 64 21Children’s Pain Management 3 62 21

Children’s Emergency 2 35 18

Emergency Department 121 2114 17Source : National Implementation Report on the Nurse and Midwife MedicinalProduct Prescribing Initiative From 1 October – 31 December 212

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Prescribers or Prescriptions?

Clinical AreaNo. of

Prescribers

Number of Prescription

Episodes

Quarterly Episodes

per Prescriber

Emergency Department 121 2114 17Care of the Older Person 104 445 4Midwifery 90 832 9Mental Health 72 60 1Diabetes 40 660 17Intellectual Disability 33 20 1Public Health Nursing 23 40 2Midwifery Labour Delivery 22 272 12Oncology 22 263 12Mental Health Community 21 11 1Respiratory 19 41 2Pain Management 19 21 1Rheumatology 16 100 6Cardiology 14 86 6Source : National Implementation Report on the Nurse and Midwife MedicinalProduct Prescribing Initiative From 1 October – 31 December 212

Prescribing Competency

12 Prescribing Competencies: 

Information Gathering

1. Take and/or review medical history 

2. Take and/or review medication history and reconcile this with medical history

3. Undertake further physical examination/ investigations where appropriate

4. Assess adherence to current and past medication and risk factors for non‐adherence

5. Identify key health and/or medication related issues with 

the patient, including making or reviewing the diagnosis

6. Determine how well disease and symptoms are managed/controlled

7. Determine whether current symptoms are modifiable by symptomatic treatment or disease modifying treatment

8. Consider ideal therapy (drug and non‐drug), taking into account actual and potential contraindications/concerns: drug–patient, drug–disease, drug–drug interactions

9. Select drug, form, route, dose, frequency, duration of treatment

12 Prescribing Competencies:

Decision‐Making

Safely and effectively communicate treatment decisions to other health professionals and the patient/carer in both the ambulatory and the inpatient setting 

10. Communicate prescribing decision in an ambulatory care setting

11. Communicate prescribing decision in an inpatient setting

12 Prescribing Competencies:

Communicate decision.Drivers for Medication Safety (IHI)

1. Reliable Medication Management Processes 

in residential care settings (acute hospitals, 

mental health facilities, nursing homes, 

hospices, maternity hospitals).

2. Good Co‐ordination of Care at interfaces 

where care is transferred in the system.

3. Patient and family involvement in their own 

care.

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The Three Buckets– James Reason (2004)

SELF CONTEXT TASK

The Three Buckets– James Reason (2004)

SELF CONTEXT TASK

PreoccupationInexperienceLack of knowledgeUnder the weatherFatigueEmotional stateLife events

Custodial attention*Discretional energy *

(extra mile)ExperienceKnowledgeFitnessSelf awareness*limited commodities eroded by bad stuff

DistractionsInterruptionsChangeHarassmentHand‐offsAuthority gradientPoor workplace

Clear instructionsGood briefingGood teamworkAvailable timeGood rapportAble to questionGood kit, etc

Multiple steps

Forcing functionsStandardizationAlerts & reminders

Three Buckets Model

� In any given situation, the probability of unsafe acts being 

committed is a function of the amount of bad stuff in all 

three buckets.

� Full buckets do not guarantee an unsafe act, nor do empty ones 

ensure safety. We are talking probabilities not certainties. 

� But with foreknowledge we can gauge these levels for any 

situation and act accordingly.

� Don’t go there! — challenge assumptions, seek help.

.

What is being prescribed?

Most prescribed items Times

PARACETAMOL 1326

IBUPROFEN 614

DICLOFENAC SODIUM 531

DICLOFENAC 473

MEFENAMIC ACID 221PARACETAMOL AND CODEINE (SOLPADEINE) 172

PARACETAMOL/CODEINE 92

Analgesics (43% of prescriptions) 3429

What is being prescribed?

Most prescribed items TimesCHLORAMPHENICOL 159PROXYMETACAINE 166LIDOCAINE/FLUORESCEIN 394FLUORESCEIN SODIUM 362LIDOCAINE 352MACROGOL 82CARMELLOSE SODIUM 105VIDISIC GEL 129Eye preparations (22% of prescriptions) 1749

Most prescribed items TimesFUSIDIC ACID 238BENZYLPENICILLIN 284AMOXICILLIN/CLAVULANIC ACID 198FLUCLOXACILLIN 173CO-AMOXICLAV 79Antimicrobials (12% of prescriptions) 972

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What is prescribed?

Most prescribed items TimesPARACETAMOL AND CODEINE (SOLPADOL / TYLEX) 157PETHIDINE 132TRAMADOL 78Narcotic/ strong analgesics (5% of prescriptions) 367WARFARIN 283Anticoagulants (4% of prescriptions) 283INSULIN ASPART (Novo rapid) 117GLICLAZIDE 127METFORMIN 125Hypoglycaemic agents (5% of prescriptions) 369

What is prescribed?

Most prescribed items TimesDIPHTHERIA,TETANUS 341HEPATITIS B VACCINE 98Vaccines (6% of prescriptions) 439

Collaborative Pharmaceutical Care Practice

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Primary Outcomes – harm reduction

Secondary Process Measures –efficiency gains

Secondary outcomes: Improved agreement within team 

The Three Buckets– James Reason (2004)

SELF CONTEXT TASK

PreoccupationInexperienceLack of knowledgeUnder the weatherFatigueEmotional stateLife events

Custodial attention*Discretional energy *

(extra mile)ExperienceKnowledgeFitnessSelf awareness*limited commodities eroded by bad stuff

DistractionsInterruptionsChangeHarassmentHand‐offsAuthority gradientPoor workplace

Clear instructionsGood briefingGood teamworkAvailable timeGood rapportAble to questionGood kit, etc

Multiple steps

Forcing functionsStandardizationAlerts & reminders

“  The real power and innovation of jazz is that a group of people can come together and create art—improvised art—and can negotiate their agendas with each other. And thatnegotiation is the art.”     ‐Wynton Marsalis