Report to: Board of Directors (Public) FoI status: Report ... papers... · The CQC rated Trust core services as compliant with Outcome 9: management of medicines and ... This target

Report to: Board of Directors (Public)

Paper number: 3.3

Report for: Governance

Report type: Governance

Date: 24 September 2015

Report author: Lucy Reeves, Chief Pharmacist

Report of: Dr Vincent Kirchner, Medical Director

FoI status: Report can be made public

Title: Medicines Management Annual Report 2014/15

Executive Summary

It is a requirement that the Trust Board receives reports on the use, optimisation and risks associated with medicines. The Chief Pharmacist / Controlled Drug Accountable Officer will produce an annual report to the Board. Key notes are:

a) maintaining robust governance through the Drug and Therapeutics Committee;

b) ensuring Trust-wide compliance with CQC essential standards for medicines management;

c) ensuring a competent workforce with regards to medicines;

d) improving medication incident reporting and trust wide learning; and

e) optimising effectiveness and efficiency within the pharmacy service.

The CQC rated Trust core services as compliant with Outcome 9: management of medicines and reported that overall management of medicines had improved. However the Trust’s own medicines management risk register showed that more improvements were needed and that these should be fully implemented so that medicines were managed safely. The action plan included fourteen actions out of which eleven are now complete with evidence of delivery (79%). The remaining three actions are currently in progress and on track for successful completion within CQC timescales.

The inpatient and community surveys showed improvements in providing service users with information on their medication, however further work is required to improve and maintain the provision of information to all service users.

Areas of concern or risks to note are:

a) safe and secure storage of medicines and prescription stationery;

b) assurance of implementation of action plans and organisational learning following medicine related incidents;

2

c) improvement in monitoring and documentation associated with rapid tranquilisation, high dose antipsychotic and hypnotic prescribing;

d) improving quality of information sent to GPs regarding service users’ medication at the point of discharge; and

e) Trust-wide medicines management training strategy and programme for all staff handling medicines.

Trust Strategic Priorities Supported by this Paper

Excellence

Continually improve the quality and safety of service delivery, service user experience and improving outcomes.

Delivering the highest level of quality and financial performance.

Risk Implications

Medicines management risks are on the Trust’s risk register.

Legal and Compliance Implications

Care Quality Commission (CQC), National Institute for Health and Care Excellence (NICE) and legislative compliance.

Finance Implications

The Quality, Innovation, Productivity and Prevention (QIPP) targets.

Single Equalities Impact Assessment

N/A

Requirement of External Assessor/Regulator

This report has been produced in line with requirements of Department of Health (Controlled Drug regulations) & CQC.

Recommendation to the Board

The Board of Directors is requested to:

receive and accept this annual report for information.

Trust Medicines Management Annual Report 2014/15

1. Leadership

Pharmacy services were provided through a contract with Whittington Health. In September 2013 notice was served on the Whittington Health pharmacy contract for the service to be brought in house on the 1 April 2014. All staff providing the service under the contract transferred, in accordance with TUPE regulations, to Camden and Islington NHS Foundation Trust under the direct management of the Chief Pharmacist.

2. Clinical Effectiveness

2.1 Drug and Therapeutics Committee

The Drug and Therapeutics Committee (DTC) met six times over the year 2014/15. A total of nineteen documents were reviewed and approved during this period (see appendix 1 for full list). This included four policy/procedures, eleven clinical guidelines and four patient group directions. Most of the documents were tabled inline with the scheduled review process, however seven were newly produced documents to support new service developments including the Trust’s smoking cessation policy, complex depression and anxiety trauma (CDAT) service and community alcohol team partnership working with third sector organisations.

In addition, nine medicine reviews were conducted for new medicines or new indications of which seven were approved for inclusion on the Trust formulary (see appendix 1 for full list). There were two new medicines launched in 2014/15; aripiprazole long acting injection for the maintenance treatment of schizophrenia and other psychosis in patients stabilised with oral aripiprazole, and lurasidone for the treatment of schizophrenia. Aripiprazole was approved by the Trust subject to North Central London Joint Formulary Committee (NCL JFC) approval (this was obtained in April 2015). Lurasidone was put forward to the JFC for consideration but was not approved (June 2015) due to insufficient evidence to support its inclusion in the formulary. Nalmefene, which is licensed for the reduction of alcohol consumption in patients with alcohol dependence who have a high drinking risk level without physical symptoms and who do not require immediate detoxification, was approved by NICE TA325 (Nov 2014) and therefore included on the Trust formulary in compliance with Department of Health requirements.

On-going formulary management and monitoring has maintained the improvements seen in the previous year regarding compliance with the Trust formulary. Prescribing of non-formulary medicines on an individual case basis is permissible on approval by the Chief Pharmacist or Medical Director, for example where there is no suitable alternative medicine on the formulary or the patient is currently stable on the medicine. Monitoring compliance with the Trust formulary policy for inpatient prescribing is a key performance indicator (KPI) for the pharmacy department. In 2014/15 twenty one non-formulary requests were submitted by consultants via the pharmacy team. 70% were for medicines that the patients were already prescribed and following review considered appropriate to continue. Only one of the requests was not approved demonstrating good adherence to Trust prescribing guidelines, formulary policy and appropriate use of the non-formulary process.

- 2 – Board Medicines Management Report 2014-15

Graph 1 below shows the numbers of non-formulary medicines and physical health care medicines being prescribed on FP10 prescriptions across the Trust for 2014/15, compared to 2013/14 and 2012/13. FP10 prescriptions are dispensed by community pharmacies and therefore governance controls for FP10 prescribing are more limited compared to in-house Trust prescribing as FP10 prescriptions are not checked by the Trust pharmacy department. Prescribing activity on FP10 prescription has increased year on year and in 2014/15, 45,000 items were prescribed. The number of non-formulary medicines and physical health medicines prescribed in 2014/15 was approximately 0.3%, for each, of the total number of items prescribed on FP10 prescription.

Graph 1: Number of non-formulary and physical healthcare medicines prescribed by FP10

2.2 NCL Joint Formulary Committee

The North Central London Joint Formulary Committee (NCL JFC) was established in September 2012. The aim being to standardise prescribing across the sector and create an NCL integrated formulary covering all healthcare providers in NCL. The Chief Pharmacist is the Trust’s representative member on the committee. All new medicines that are intended for prescribing across secondary and primary care within the sector must be approved by the Joint Formulary Committee. One new medicine application was submitted by the Trust to the JFC, for the use of aripiprazole long acting injection, which was approved in April 2015.

2.3 Research and Development

The pharmacy clinical trials service is operational and provided via Whittington Health pharmacy clinical trials unit.

2.4 CQUINs

There were three medicine related CQUINs set in 2014/15:

CQUIN 4.3 Reduction of medication errors through medicines reconciliation on admission to hospital.

Medicines reconciliation is a process to ensure medicines prescribed on admission correspond to those that the patient was taking before admission, unless changes have been made for a specific clinical reason. 95% of patients


admitted should have medicines reconciliation documented in accordance with POMH-UK definition and audit criteria based on NICE/NPSA standards. This target was achieved in quarters 3 and 4. This target is also an ongoing KPI for the pharmacy department.

CQUIN 5.1—Smoking Cessation

This CQUIN aims to promote better health outcomes for service users through brief lifestyle intervention, namely increasing the stop smoking offer for service users in contact with health services. To support this programme prescribing guidelines for smoking cessation and Patient Group Directions for nicotine replacement therapy were developed and implemented to enable nursing staff to supply at the point of admission. In Q.4 nicotine patches and inhalators were issued at higher rates than in the previous three quarters, with a total of 59 patients dispensed NRT in the quarter compared to 27 in Q1. This figure does not include patient issued with NRT from ward stock and therefore is not a representation of the total number of patients actually issued with NRT. This increase is a result of ensuring patches and inhalators are available as stock on wards for nursing staff to supply NRT to smokers at the point of admission and to support the introduction of smoke-free sites.

CQUIN 6.2—Medication Adherence

The Trust must establish the proportion of service users admitted where non-adherence with prescribed medication is recorded as a contributory factor to admission through a sample of inpatient admissions audited in the quarter. For Q4, the overall trust-wide score was 61% which was an increase from the score of 47% reported in Q2. Further work is planned to support service users to improve concordance with their prescribed medicines, including clearer information at the time of prescribing and access to ongoing support and advice in the community.

3. Safety

3.1 CQC Essential Standards, Outcome 9 – Management of Medicines

In May 2014 the CQC inspected Trust core services as part of the comprehensive Wave 2 pilot mental health inspection programme. The team of 35 people included CQC inspectors, Mental Health Act commissioners, a pharmacist inspector and two analysts. They also had a variety of specialist advisors which included consultant psychiatrists, psychologists, senior nurses, junior doctors and social workers. Services inspected included:

Adult admission wards;

Health-based places of safety;

Psychiatric intensive care unit;

Services for older people;

Adult community-based services; and

Community-based crisis services.

Key points from the report included:

The pharmacy service has been brought in-house and the management of medicines has improved.

Arrangements for the supply of medicines were good, so people did not have delays in receiving treatment.

Medicines were stored safely in the areas inspected. Prescription charts were clear and fully completed in all areas except one, providing evidence that people were receiving their medicines as prescribed, when they needed them.


Medicine management at Stacey Street Nursing Home was now working well and the compliance action from the previous inspection was completed.

The latest medicines incident report showed that there had been 40 medicines-related incidents across the trust in the three-month period between January and the end of March 2014, with only 3% resulting in minor injury (adverse reaction to drug) which is comparable to other quarters.

Service users were provided with information about their medicines. Pharmacist and ward staff both discussed changes to people’s medicines, and mental health medicines information leaflets were available for service users.

Ward staff we spoke with told us that arrangements for medicine supplies were good. This meant that patients had access to medicines when they needed them without delays.

Some improvements were needed in recording and transportation of medicines in the crisis team at Highgate Mental Health Centre. Also, some improvements were needed in the psychiatric intensive care unit where observations of people who had received rapid tranquilisation needed to be consistently recorded.

Overall management of medicines had improved across the Trust, however, the Trust’s own medicines risk register showed that more improvements were needed and that these should be fully implemented so that medicines were managed safely.

An action plan was implemented to ensure and assure compliance within set time scales. The specific CQC essential standard actions related to Medicines Management to assure and ensure compliance were reviewed and signed off by the Trust Quality Review Group. This included fourteen actions out of which eleven are now complete with evidence of delivery (79%). The remaining three actions are currently in progress and on track for successful completion within CQC timescales.

The risk rating against the risks listed in the medicines risk register have subsequently been downgraded from high risk to moderate risk. Although the likelihood of a serious incident is now unlikely there is a potential risk for a moderate level harm associated with medicine incidents.

3.2 Medicines Incidents

Graph 2: Medication incidents by division


The total number of medicines incidents reported trust wide in 2014/15 was 222 which is double the number reported in 2011/12 (114), demonstrating a significant year on year improvement in reporting. The Acute and Recovery and Rehabilitation divisions reported the highest number of incidents, which is to be expected as these divisions are most directly involved in the prescribing and handling of medicines. Reporting rates are relatively lower for other divisions but all have improved on the previous year except within the Community Division.

Graph 3: Medication incidents by severity

All incidents reported in 2014/15 were rated as causing no injury (97%) or minor injury (3%). In line with the previous year there were no incidents resulting in moderate or more serious injuries. This demonstrates further improvements on developing and embedding a positive reporting culture.

Medicine incidents account for 4.7% of the total number of incidents reported by the Trust to the National Reporting and Learning System (NRLS). This is a slight increase from the previous year (4.5%). For all mental health provider organisations in England this proportion is 9%, suggesting that medicines incidents remain under reported in the Trust.

Medication incidents are reviewed at the DTC. Current themes and action plans to address these are reported to the committee. In March 2014 MHRA and NHS England issued a Patient Safety Alert, Stage Three - Directive: Improving medication error incident reporting and learning. In accordance with the required actions multi professional medicine safety groups were introduced for inpatient and community services to provide a forum for practice level staff to review medication incident reports, share learning and take local action to improve medication safety. Actions have included designing and implementing a weekly audit of medicine charts, piloting new systems for stock and non-stock management on the wards, and a new system in place for safe & secure storage/access of duplicate keys where urgent replacement key required.

In addition, a medicines safety bulletin was published highlighting specific incidents and learning points. A Medicines Management lead nurse was appointed in February 2015 and is the Trust’s designated Medicines Safety Officer as defined in the MHRA/NHSE Patient Safety Alert. The responsibilities of this role include being a


member of the National Medication Safety Network, supporting local medication error reporting and learning and acting as the main contact for NHS England and MHRA.

3.3 Controlled Drugs (CDs)

All healthcare organisations are required to promote safe and secure use of controlled drugs and to ensure compliance with relevant legislative and regulatory requirements. A quarterly audit is conducted at all sites holding controlled drugs with action plans implemented where necessary.

CD incidents

A total of forty five controlled drug related incidents were reported in 2014/15. Thirty incidents were reported by Substance Misuse Services however, sixteen of these were directly related to errors on the part of community pharmacies or acute trusts dispensing for SMS service users, and six related to service users losing their prescription or medication.

The majority of controlled drug incidents related to non-compliance with dispensing procedures for SMS clients (16) and controlled drug record discrepancies (11). All controlled drug record discrepancies were resolved following investigation except one which involved the unaccounted loss of four buprenorphine tablets from the pharmacy department. Appropriate management action was taken in accordance with the Trust Controlled Drug policy.

In fourteen cases the incidents directly resulted in the service user not receiving appropriate treatment: wrong dose administered (4), wrong medicine administered (1), missed dose (4), dose administered without review following 3 day break (5). None of the incidents resulted in any harm to the service users.

Controlled Drug Training

Local training needs have been identified and a training programme has been developed and delivered locally by pharmacy staff. Sites where there are shortfalls in policy adherence have been prioritised. In addition, the Trust has purchased a comprehensive medicines management e-learning programme that includes controlled drugs. Competency in handling and record keeping for controlled drugs is included in the Trust’s Assessment of registered nurses in the safe administration of medicines. Application of the assessment has been inconsistent across the trust however the newly appointed Medicines Management lead nurse will be responsible for reviewing the programme and improving implementation to ensure staff are trained and competent in the handling of controlled drugs.

Controlled Drugs Accountable Officer activity

The Chief Pharmacist is the designated Controlled Drugs Accountable Officer (CDAO). The Trust’s CDAO is responsible for the safe and effective use and management of controlled drugs and has a statutory responsibility to provide quarterly occurrence reports to the NHS England (London) CDAO. These reports detail any concerns regarding management or use of controlled drugs across the Trust or other organisations/agencies involved. All occurrence reports have been completed and submitted as required. The NHSE (London) CDAO team actively follow up all incidents reported by the Trust CDAO involving external organisations. The CDAO is a member of the NHS England (London) local intelligence network (LIN) which meets six monthly, both meetings were attended.


3.4 Never Events

There have been no recorded medicines related never events in the past year

3.5 Patient Safety Alerts

Four patient safety alerts were issued jointly by the MHRA and NHS England during 2014/15. All actions relevant to the Trust were completed.

Improving medication incident reporting.

Risk of distress and death from inappropriate doses of naloxone to inpatients on long-term opioid/opiate treatment.

Risk of death or serious harm from accidental ingestion of potassium permanganate preparations.

Harm from using Low Molecular Weight Heparins when contraindicated.

3.6 Audits

A pharmacy audit plan was produced for 2014/15 in accordance with the Trust annual clinical audit plan, which was agreed at the DTC and approved by the Quality Committee. The programme included national and local audits and is listed in appendix 2.

Safe and Secure Handling of Medicines Audit

In 2012 a baseline audit was conducted of the safe and secure handling of medicines. This audit has since been repeated Trust-wide annually to demonstrate compliance with CQC standards for medicines handling. Additional criteria were included in the audit tool this year to monitor compliance against a broader range of standards. Appendix 3 shows the percentage compliance across the trust for all criteria monitored in September 2014 and comparison to previous audits 2012 and 2013. For the majority of standards (60%) services were 95-100% compliant. Action plans to address the shortfalls have been implemented in liaison with pharmacy and service managers. Regular audits are now conducted locally by services to monitor ongoing compliance.

Key areas of concern or risk to note are:

daily monitoring of room temperature;

daily monitoring of medicines fridge temperature and lack of knowledge/action if LEC fridge temperature is outside usual range;

oral (purple) syringe availability on wards/off site units;

storage of medicines and flammable liquids;

expiry date checks; and

daily checks of emergency medicines bags.

POMH-UK audit

The Prescribing Observatory for Mental Health (POMH) audit programme aims to improve the quality of prescribing practice and medicines use nationally. Participating in POMH audit is currently voluntary for teams but is recommended that divisions consider making it mandatory for teams to participate in relevant POMH audits.

In 2014/15 there were two POMH audits conducted relevant to the Trust; Prescribing to people with a personality disorder and Antipsychotic prescribing in people with a learning disability. Data was not submitted to POMH at the time of the audit of prescribing practice in people with personality disorder however data was collected at a later date using the POMH audit tool and will be compared against the national


results. Data for the audit of antipsychotic prescribing in people with learning disability was submitted to POMH. Reports for both audits are still pending.

Clinical practice audits

High dose antipsychotic prescribing (re-audit of 2013): Overall, there have been some improvements in prescribing and monitoring high dose antipsychotic treatment compared to the last audit, but further improvements are required. The number of patients prescribed HDAT has notably reduced over the years the audit has been conducted 70 (2011), 26 (2013), 16 (2014). Actions to be reinforced to improve performance include:

Pharmacists to ensure prescribers aware if prescribing exceeds 100% maximum licensed dose, either as single antipsychotic or combined, and to endorse medication chart.

Pharmacists to ensure HDAT forms completed during patient admission and will remind medical teams to undertake the recommended monitoring.

Pharmacists will request reviews of HDAT prescriptions if on-going for more than six weeks.

At discharge the GP should be notified that the patient is being prescribed HDAT and of the necessary monitoring to be done. Pharmacists now ensure the information is included on the discharge notification form as a KPI.

Rapid Tranquilisation (re-audit of 2013): All patients were prescribed in accordance with Trust guidelines for rapid tranquillisation. Physical monitoring of patients pre and post administration of rapid tranquilisation has improved from previous audits however debriefing remained poorly documented. The implementation of the MEWS chart has facilitated documentation of physical observations. Further action to improve training and competency assessment of staff will be implemented as part of the trust medicines management training strategy for staff.

A baseline audit of prescribing and administration of hypnotics was conducted to monitor compliance against the trust guidelines for management of insomnia. In all cases patients were prescribed appropriate hypnotic medicines in accordance with Trust formulary and guidance however shortfalls were identified around initial assessment of sleep patterns and underlying causes of insomnia and subsequent review of prescriptions. The following actions have been introduced to improve performance:

A sleep history should be undertaken, to establish underlying causes and patterns, on admission and documented. Hypnotic prescribing should only be considered after that and the rationale documented.

Patients should be counselled about sleep hygiene, short-term use of hypnotics and, the risk of tolerance, dependence and withdrawal symptoms. They should also be provided with patient information leaflets. This should be documented.

Hypnotics should be reviewed at least every week and documented.

Pharmacists to highlight on the prescription charts if patients have received hypnotics on a regular or as required basis for more than two weeks and discuss with the doctor an appropriate course of action.

Hypnotics should not routinely be prescribed on discharge. If hypnotics are prescribed on discharge, this will be challenged by the pharmacist clinically screening the discharge prescription. If continued use is indicated the GP must be sent a care plan, clearly stating why treatment should be continued and next review date.


A baseline audit of discharge notification forms was undertaken to determine the trust’s compliance against the minimum dataset for information on medicines which should be provided on discharge from hospital. Actions underway to improve the quality of data include:

Inform prescribers at induction on dataset requirements for discharge notification forms (DNF).

Procedure for DNF to be produced and implemented across the Trust.

Review the current DNF template and include as standard document on new EPR system.

Ensure audit trail of DNF and date sent to GP.

Antimicrobial prescribing: Prescribing is audited on an on-going basis by ward pharmacists and reported as a standing item at the DTC and Infection Control Group. Monthly reports are sent to relevant consultants. Clinical monitoring and greater awareness of antimicrobial prescribing policy has improved prescribing practice as a result.

4. Patient Experience

4.1 CQC Mental Health Patient Survey, 2014 – 2015

Inpatient survey 2014

Measure % Yes 2013

% Yes 2014

% Yes National

2014

During your most recent stay, were you given any medication (including tablets, medicines and injections) as part of the treatment for your mental health?

85% 98% 94%

Did the hospital staff explain the purpose of this medication in a way you could understand?

60% 66% 78%

Did the hospital staff explain the possible side effects of this medication in a way you could understand?

33% 46% 52%

Community patient survey 2015

Measure % Yes 2014

% Yes 2015

% Yes National

2015

In the last 12 months, have you been receiving any medicines for your mental health needs?

85% 83% 84%

Were you involved as much as you wanted to be in decisions about which medicines you receive?

86% 85% 88%

In the last 12 months, have you been prescribed any new medicines for your mental health needs?

40% 46% 46%

The last time you had a new medicine prescribed for your mental health needs, were you given information about it in a way that you were able to understand?

88% 78% 85%

Have you been receiving any medicines for your mental health needs for 12 months or longer?

88% 87% 87%


In the last 12 months, has an NHS mental health worker checked with you about how you are getting on with your medicines?

81% 83% 78%

The results for the inpatient survey demonstrate a continuous improvement in providing service users with information about their medication. However the results remain slightly below the national level and indicate that further work is required to improve satisfaction levels. The community patient survey shows a much better picture of patient satisfaction with being involved in decisions about their medication and the information provided.

There is a CQUIN target set for 2015/16 to ensure service users are provided with the necessary information at the time of prescribing new medicines. Plans to support the achievement of this target include greater promotion of ‘Choice and Medication’ web portal which provides accurate, independent information and education about medicines in a range of formats to staff, service users and carers, and greater engagement of pharmacy staff in discussions with service users regarding their medication. All inpatients prescribed lithium have their medication explained and are provided with patient information booklet and by the pharmacy department. This is monitored as part of the pharmacy department KPIs.

5. Pharmacy Activity

Pharmacy services for the Trust were previously delivered through contract by Whittington Health. On 1 April 2014 all staff providing the service under the contract transferred to C&I in accordance with TUPE regulations. The pharmacy team consists of 18 (16.8 WTE) staff of which 10 are pharmacists. Three of the pharmacists are practicing independent non-medical prescribers. Funding for an additional pharmacist and pharmacy technician was approved in March 2015 to support provision of pharmacy services to community based teams and bedded services.

5.1 Medicines Supply

Medicine supplies are issued from the dispensary at Highgate Mental Health Centre (HMHC).

Graph 4: Dispensary activity

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

2012/13 2013/14 2014/15

Inpatient issues

Outpatient issues

TTOs

Ward distribution (stock items)

Total Issues

Supply of medicines represents a significant component of the pharmacy with 48,327 items being supplied in 2014/15. This represents a 3% increase in overall activity on previous year from 47,105 items, which is mainly due increased patient throughput and pharmacy taking on more dispensing for crisis teams and crisis houses. Initial benefits of streamlining the supply function by merging the two dispensaries have been maintained, particularly in relation to ward stock management. Further work to


improve the efficiency of stock management in the community teams is planned for the next year with the appointment of new pharmacy staff. The shift in distribution between outpatient and medicines ‘to take out’ when on short term leave or discharge from hospital (TTOs) is due to an anomaly in the pharmacy IT system, resulting in outpatient clozapine dispensing for certain clinics being recorded as TTO activity. This has since been corrected.

5.2 Clinical Pharmacy activity

Previously clinical pharmacy activity was very restricted across the Trust. These figures represent clinical pharmacy activity to all inpatient wards, crisis teams, crisis houses and rehabilitation houses. Since merging the dispensary functions in July 2013 ward based clinical pharmacy activity has significantly increased and been sustained. The notable increase in number of contributions made towards service user’s treatment plans and medicine information queries demonstrates more proactive intervention by the pharmacists and greater recognition and utilisation of pharmacists by clinical staff. The dip in activity recorded from March to June 2014 was around the period of the CQC inspection when the pharmacy team were proactively supporting all teams across the trust to ensure compliance with standards for medicines management. This led to diversion of activity from the wards to community based teams. In addition there was a relatively high proportion of agency staff at the time keeping limited records of clinical activity. Further work is planned to enable increased pharmacist attendance at Board meets (multidisciplinary meetings to discuss current admissions), ward rounds and to increase direct engagement by pharmacy staff with service users to discuss medications. It should also be noted that from November 2014 medicines reconciliation has been conducted predominantly by pharmacy technicians whose activity is included in this data. All pharmacy technicians within the department have either completed or are in the process of completing the Accreditation in Medicines Management certificate. This has enabled a far more effective use of the department skill mix.

Activity

Total

(2013–2014)

Total

(2014–2015)

Consultant led ward rounds / board meets attended 132 141

Contributions made to treatment plan during ward round / board meet 402

314

Contributions made to treatment plan outside ward round 1,360 2642

Patient 1:1 sessions 101 71

Medicines reconciliation 822 1694

Medicines information queries 246 563

Medicines incidents reported on Datix and/or involvement in action plan 60

76

SOAD activity 8 43


Total clinical pharmacy activity 2013-2015

6. Medicines expenditure

Medicines Expenditure vs. Budget

Service 2013/14 2014/15

Budget Expenditure Variance Budget Expenditure Variance

SMS £952,576 £882,614 £69,962 £866,255 £850,901 £15,354

Mental Health

1,264,413 £1,284,328 (£19,915) £1,180,570 £1,432,679 (£252,109)

Total £2,216,989 £2,166,915 £50,074 £2,046,826 £2,283,580 (£236,755)

The Trust’s total medicines expenditure showed an overall over spend against budget in 2014/15. Expenditure across mental health services was again over budget and increased by 12% on the previous year. The increase is due to increased expenditure on antipsychotic long acting injections (LAI), in particular the newer atypical antipsychotics which are considerably more expensive, and nicotine replacement treatment. LAI expenditure has increased by £250,000 from last year and accounts for 69% of total medicine expenditure across mental health services (62% 2013/14). There have been no price increases for any of the products, therefore this is a direct result of increased prescribing activity seen with all LAI products. Plans are in place to ensure efficient prescribing and stock management of LAI in the trust. Sessions are planned with consultants to provide evidence based information on LAI treatment to support clinical decision making on the most clinically appropriate and cost effective choice for the individual patient.


Appendix 1

Drug and Therapeutics Committee – Documents reviewed (2014/15)

Policy / procedure

Formulary policy (review)

Non-Medical Prescribing policy (review)

Medicines Reconciliation procedure (review)

CASA ISATS community alcohol procedure (new)

Guidelines

Anxiety disorder prescribing guidelines (new)

Management of anaphylaxis guidelines (review)

Medically assisted community alcohol withdrawal (review)

Depression prescribing guidelines (new)

Prescribing guidance for managing behavioural disorders in adults with learning disability (new)

Guidance for safer use of injectable medicines (review)

Depot antipsychotic medication guidelines (review)

Management of insomnia guidelines (review)

Prescribing in smoking cessation (new)

Guidance for the use of zuclopenthixol acetate (Clopixol acuphase®) in adults (review)

Rapid Tranquilisation guidelines (amendment)

Patient Group Directions (PGD)

PGD for the administration of hepatitis B vaccination for adult clients in Substance Misuse Services (review)

PGD for the administration of hepatitis A&B vaccination for adult clients in Substance Misuse Services (review)

PGD for administration of nicotine replacement therapies for inpatients (new)

PGD for administration of nicotine replacement therapies for community patients (ACOT) (new)

Medicine Reviews

Venlafaxine for treatment in panic disorder (approved)

Aripiprazole long acting injection for maintenance treatment of schizophrenia and other psychoses in patients stabilised with oral aripiprazole (approved)

Zolpidem short term treatment of insomnia (approved)

Nicotine oral spray for treatment for smoking cessation (approved)

Bupropion for off-label treatment of depression (approved)

Melatonin for treatment of insomnia (not approved)

Nalmefene for reduction of alcohol consumption (NICE TA)

Lurasidone for treatment of schizophrenia (referred to NCL JFC – not approved)

Emergency drug list (reviewed)


Appendix 2

Pharmacy audit programme 2014/15 – completed audits

Month Topic Source Compliance requirement

Monthly Missed doses Trust medicines management policy

CQC Outcome 9: Medicines management.

Monthly Antimicrobial prescribing

Trust Antimicrobial prescribing policy

Criterion 9 of the Health and Social Care Act 2008


Monthly Lithium - monitoring of inpatients prescribed lithium

POMH - UK (Topic 7) CQC Outcome 9: Medicines management.

NPSA patient safety alert.

NICE guidance

Quarterly Controlled Drugs Trust Controlled Drug policy

Statutory - DH

Sep-14 Safe & secure handling of medicines and prescription stationery

Trust Medicines management policy


Oct-14 Pharmacy endorsing standards

Trust Pharmacy endorsing standards


Nov-14 High dose antipsychotic prescribing

Trust Antipsychotic prescribing guidelines


NICE guidance

Jan-15 Prescribing and administration of hypnotics

Trust management of insomnia guidelines


NICE guidance

Feb-15 Discharge notification forms

Trust Medicines management policy, NCL Medicines Optimisation Network Prescribing Guidance


Mar-15 Rapid Tranquilisation Trust Rapid Tranquilisation guidelines


NHSLA risk management standards.

NICE guidance


Appendix 3

Safe and Secure Handling of Medicines Audit Outcomes Sept 2014

Description Standard Description 2012

%met

2013

%met

2014

%met

1.Disposal of Medicine

1. Yellow sharps bins (waste disposal bins) are available and used only for disposal of sharps/medicines waste.

95% 98% 93%

2. Blue waste disposal bins are available and used only for disposal of medicines waste (excluding sharps and cytotoxic).

63% 84% 90%

3. Purple lidded waste disposal bins are available for and used only for disposal of cytotoxic waste (where applicable – pharmacy have advised where cytotoxic medicine in use).

New in

2014

New in

2014 97%

4. Unused medicines awaiting return to pharmacy are securely stored.

New in

2014

New in

2014 100%

2. Storage Temperature & Refrigerators

5. Temperature of room(s) where medications are stored is monitored and recorded. The temperature is maintained below 25°C. (This includes patient’s rooms where appropriate.)

New in

2014

New in

2014 67%

6. Temperature of refrigerator is measured using a calibrated maximum-minimum thermometer only.

86% 100% 93%

7. Temperature of refrigerator is measured using a calibrated maximum-minimum thermometer only.

New in

2014

New in

2014 90%

8. There is a record of daily monitoring showing temperature is between 2 and 8°C (excluding weekends if clinic is closed). Note: calculate the % of times the daily record has been made within the last month.

88% 100% 93%

9. Staff know what action to take if excursions are seen.

New in

2014

New in

2014 83%

10. Refrigerator only contains stock of pharmaceutical products.

88% 100% 100%

11. All refrigerators storing medicines are locked and in lockable rooms.

72% 95% 90%



%met

2013

%met

2014

%met

3. Controlled Drugs

12. CD cupboard keys are in possession of nurse in charge or equivalent or a nominated deputy, separately from all other keys. (NB. may be kept together if no CDs currently held on ward.)

New in

2014

New in

2014 97%

13. CDs are stored separately from all other medicines.

New in

2014

New in

2014 100%

14. The CD cupboard(s) is bolted to the floor or a solid wall or has been approved by the local police CD Liaison officer, and is always locked when not in use.

New in

2014

New in

2014 100%

15. There is only one ward CD order book in active use at any time and it is stored securely when not in use.

100% 100% 100%

16. The ward CD record book shows evidence of regular stock checking by ward staff (after each administration and receipt) and by pharmacy staff (at least 3 monthly), in accordance with the requirements of Trust policy.

New in

2014

New in

2014 100%

17. Is documentation complete in ward CD record book e.g. signatures, for ordering, supply, receipt and administration). Check all entries since last audit.

New in

2014

New in

2014 97%

18. Have the CD order book records been correctly entered in the CD record book.

New in

2014

New in

2014 100%

19. Do stock balances tally with record book balances?

New in

2014

New in

2014

100%

20. If there are discrepancies have these been accounted for and recorded correctly (e.g. no crossing out)?

New in

2014

New in

2014 100%

21. Expired or unwanted CDs for destruction / to be returned to pharmacy are stored securely and segregated from “in-use” CD stocks.

New in

2014

New in

2014 97%

22. Do entries in the CD record book match the medicine chart.

New in

2014

New in

2014 100%



%met

2013

%met

2014

%met

4. Other Stock Medicines Storage

23. Clinic room / medicines storage room is kept locked.

New in

2014

New in

2014 100%

24. Clinic room / medicines storage room is kept tidy. Is the workbench area clear of clutter and clean

New in

2014

New in

2014 100%

25. Oral (purple) syringes available for administration of liquid medicines.

New in

2014

New in

2014 67%

26. All medicines are stored in locked cupboards (fixed to wall or ceiling and preferably steel not timber construction) / medicines trolleys. i.e. medicines are not stored on worktops, open shelves or in filing cabinets.

93% 100% 100%

27. All medicine trolleys are immobilised, e.g. secured or clipped to the wall in the treatment room when not in use on the ward (include all trolleys).

84% 100% 100%

28. There is adequate storage space and medicines for internal & external use appropriately segregated?

New in

2014

New in

2014 87%

29. Flammables such as alcoholic disinfectants are stored appropriately in a locked, steel cupboard.

New in

2014

New in

2014 73%

30. IV fluids are appropriately stored in a secure, dedicated area?

New in

2014

New in

2014 100%

31. Newly delivered medicines are stored securely whilst awaiting transfer to medicines cupboards.

New in

2014

New in

2014 97%

32. There is no expired stock in the ward/unit in medicines cupboards and trolleys (includes stock/non-stock/TTAs/PODs).

65% 97% 90%

33. All medicines are annotated with date of opening/expiry date, where applicable (e.g. eye drops).

New in

2014

New in

2014 87%

34. Patient’s medicines for self-administration are stored securely in locked bedside cupboards which are secured to the bedside locker/wall/floor (or in the ward medicines trolley/cupboard).

New in

2014

New in

2014 97%



%met

2013

%met

2014

%met

5. Emergency Medicines

35. If present, the emergency medicine bag is readily accessible (nurse office or clinic room).

New in

2014

New in

2014 100%

36. The bag is sealed with a tamper-evident seal. New

in 2014

New in

2014 93%

37. The bag is expiry dated and in date. New

in 2014

New in

2014 100%

38. There is an anaphylaxis pack, which is in date. New

in 2014

New in

2014 93%

39. There is a procedure for checking daily that the emergency medicine bag is checked and in date and seal intact.

New in

2014

New in

2014 87%

40. Naloxone, Flumazenil and procyclidine are kept as stock (separated for ready access) in the medicine cupboard on each ward.

New in

2014

New in

2014 97%

6. Medical Gas cylinders

41. Adequate facilities are available for safe and secure local storage (racks or chains, and appropriate trolleys) of medical gas cylinders and associated equipment.

New in

2014

New in

2014 100%

42. Stocks are limited to “immediate needs” and regularly used gases only. Full and empty cylinders are segregated and readily identifiable.

New in

2014

New in

2014

100%

43. Local medicines policy requires that oxygen is administered only on prescription (except for emergency use).

New in

2014

New in

2014 100%

7. Security / Controlled Stationery

44. The following stationery is kept secure i.e. locked in a safe or locked in a cupboard or in a staffed nursing office:

• outpatient prescription charts; and

• inpatient medicine charts.

New in

2014

New in

2014 93%

45. Inpatient wards/units: Medicines cupboard keys are in possession of nurse in charge or equivalent or a nominated deputy OR in locked cupboard if in a Community Unit (briefly describe nature of cupboard and who has access).

98% 98% 97%

46. If mechanical digital locks are used, is confidentiality about codes maintained.

New in

2014

New in

2014 97%



%met

2013

%met

2014

%met

47. Are swipe locks or other e-technology in use? New

in 2014

New in

2014 0%

8. Medicine Policy

48. Are staff aware of the Trust:

• Medicines Policy; and

• Controlled Drug Policy and Standard Operating Procedure.

Do ward/clinic staff show appropriate awareness & understanding of their responsibilities for safe & secure storage of medicines security?

100% 100% 100%

49. Do staff know where to find a copy of the Trust Medicines Policy?

New in

2014

New in

2014 97%

50. Have staff had training on any aspects of the Medicines policy / Controlled Drug policy within the last 12 months?

New in

2014

New in

2014 83%