CARE HOMES


In terms of patients receiving errors: 39.1 per cent received a prescribing error, 18.4 per cent a monitoring error, 36.7 per cent a dispensing error and 22.3 per cent observed to receive an administration error.


Examples of prescribing errors included:


• Not knowing the resident


• Prescribing without computerised notes or prescribing software


• Poor communication between primary and secondary care


Administration errors could result from poor ordering of medicines and poorly trained staff. (The RPS 2012 report had actually found that errors were more likely to be in the non Monitored Dosage Systems (MDS) medicines, such as inhalers, rather than in required medicines. The report’s authors found that there tended to be an ‘over focus’ on the MDS, with sub-optimal management of non MDS linked to training.)


According to CHUMS, dispensing errors were partly related to MDS that use cassettes, and were therefore more likely to have labelling problems, and to the millions of tablets repackaged weekly into MDS.


The study concluded that there was ‘an unacceptable prevalence of medication errors in care homes, affecting some of the most vulnerable members of society’.


‘Action,’ the authors said, was required from ‘all concerned’ and that improvement could be made if the medics and pharmacists providing services actually knew the residents.


THE ROLE OF COMMUNITY PHARMACISTS


Community pharmacies have invested hugely in the care home sector to support the grown number of people requiring care and also provide a number of services free of charge to care homes such as medication supplied in monitored dosage systems (MDS) and delivery of all medication up to twice daily.


Care homes usually obtain their regular supply of medicines for all their residents from one pharmacy. Increasingly, care home supply services from multiples are being centralised into a ‘hub and spoke’ model. Although more efficient, reports indicate that this can affect the local


connection between the community pharmacist, the care home and the GP practice. As a result, different models are being explored and developed by some pharmacies.


For some years now, community pharmacists have stressed their desire to do more if given the opportunity through new services designed to identify and meet the pharmaceutical care needs of people in care homes. One NHS Board, NHS Tayside, has, over the past four years, developed a new service, which is achieving positive outcomes. The Nursing Home LES for Community Pharmacy, which is designed to align to the GP LES, includes level 1 and level 2 medication review and clinical audit and provides a model for change that evolved from the original Pharmacy Advice Visit (PAV). Some pharmacies also have a dedicated Care Home Services Team that provides an enhanced input, including clinical audit to care homes.


SO, HOW CAN THE INCIDENCE OF MEDICATION ERRORS BE REDUCED? Previously, many care homes used the 28-day MDS system, but, in 2013, the Care Inspectorate said this system was no longer ‘best practice’ and, as a result, many pharmacies are now switching over to the original packs from the manufacturer and delivering these to the care homes.


Attracta Vardy, Care Services Manager for Davidsons Chemist, who provides training and support for care homes, believes that this move can only bring benefits to the homes and patients alike.


‘I think this switch to original packaging is a great move,’ Attracta told SP. ‘For a start, in light of the fact that the health boards are trying to reduce wastage, this new system will be very helpful because, with the MDS system, there was always a vast amount of medicines left over and these had to be returned by the care homes to the pharmacies.


‘The fact that the medicines are now in their original packaging means that, in the event that a patient is sick or sleeping at the time when medicines are being distributed, or is refusing to take it, then the medication that is left over can be carried over to the next cycle because it is still in the original packaging.


‘Research has shown that, when the


medicine is in the original packaging, then there is a decrease in the number of errors, as it forces the staff to do final checks before handing the medication to the residents.


‘The MDS system - which saw the dosette boxes prepared in advance – could often lead to complacency among staff, who tended to simply hand the boxes over to the patients. This return to the original packaging ensured that best practice was enforced.


‘There is no doubt that pharmacists should be providing training for carers in care homes. It is now legislation that staff in care homes – whether they are nurses or carers – have to prove to the Care Inspectorate that they have undergone adequate training.


‘I use the Numark training pack, which is accredited by the Royal Pharmaceutic al Society and provide a full day’s training to the care home staff. At the end of the day, each member of staff, who attends the training, has to undergo an assessment. The fact that, in the care homes, managers also have to assessments for competency means that safety levels for patients have probably never been higher.


‘I think that the fact that nurses and carers now have to undergo the Scottish Social Services and Care training and that the carers have to be registered is also very beneficial to the system. It’s all about accountability, but it proves that pharmacy is determined to implement the most rigorous standards throughout Scotland’s care homes.


‘With medication, it’s a matter of making sure that carers are aware that they are giving correct dosages of medicines. Where previously they simply relied on the pharmacist putting the correct dosage into the MDS boxes, the carers now have to carry out their own checks.


‘The pharmacist is also cutting down on time in pharmacy processes with regard to the medication for care homes. This frees up their time to provide training for the care home staff.


‘At the moment, there are still some care homes, which are using MDS. I am currently helping some pharmacies to move over to the new system. In addition, I’m also focussing on


providing the care homes with the training and support that the staff need.


‘To date, the response has been very positive across the board. NHS Tayside have been very proactive in sending out information to bring care homes up to date and this has certainly helped to ‘spread the word’. Some care homes are leaving it until later, but there’s no doubt that those homes, which have already implemented the new system, are already seeing the benefits’


RPS has also been focussing on improving patient outcomes with the publication in 2013 of a better use of multi-compartment compliance aids guidance.


‘The guidance,’ says Annamarie McGregor, Practice Development Lead at RPS Scotland, ‘reminds everyone of the risk of poor stability when removing certain medicines from their original pack and highlights some of the inherent difficulties relating to their inappropriate use, including waste and the need for individual assessment.


‘I am aware of some community pharmacies that have saved so much time by going back to OP rather than MCAs and that they are providing a pharmacist and technician one day per month to support improvements in medicines management. Pharmacists should quote the MCA Guidance and the care homes report when trying to change culture and practice within care homes.


‘RPS in Scotland is still working to improve pharmaceutical care and medicines management in care homes and we believe that every care home should have dedicated and regular input from a pharmacist and technicians.


‘During the summer, RPS in Scotland undertook a review of progress in achieving the recommendations from the 2012 report. There has been some work achieved through polypharmacy reviews and there are still pockets of best practice, but few dedicated roles. We plan to focus on pharmacy input to care homes and supported care settings in 2018 and were delighted to see that ‘Achieving Excellence in Pharmaceutical Care’ includes care homes as a priority.’ •


SCOTTISH PHARMACIST - 39


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