In Scotland, one in five adults are dispensed five or more medicines at any one time and there are 4 million prescribing errors occurring in primary care every year. With a pharmacy almost on every high street, the numbers involved are huge which is why improving safety in pharmacy, particularly around high risk medicines, is a vital piece of work.
As a community pharmacist and the National Pharmacist Clinical Lead for the Scottish Patient Safety Programme, I’m working with pharmacies to help improve safety.
A few years ago, I became involved in some pilot work within NHS Grampian as part of the Scottish Patient Safety Programme (SPSP) Pharmacy in Primary Care Collaborative, which was funded by The Health Foundation.
We tested a pharmacy Patient Safety Climate Survey, which produces a ‘snapshot’ of the safety culture in a pharmacy. It is designed to start a conversation about patient safety and provide a focus on where pharmacies can make improvements. We also tested care bundles for warfarin and for non-steroidal anti-inflammatory drugs (NSAIDs), which are a range of medicines that can relieve pain, reduce inflammation, and bring down a high temperature. These can include medicines such as aspirin and ibuprofen. NSAIDs are widely available on prescription and across the counter. However, this class of drugs is associated with more emergency hospital admissions due to adverse drug reactions than any other class of medicine. Some UK studies have shown that almost 30% of all adverse drug reaction related hospital admissions are linked to NSAIDs and Scottish data indicates that NSAIDs are implicated in over 50% of all bleed related hospital admissions and 60% of deaths due to bleeds. As both the bleed risk and the Acute Kidney Injury (AKI) risk are linked to NSAIDs, these outcomes are predictable, and therefor potentially preventable.
We discovered that pharmacies undertaking the Pharmacy Patient Safety Climate Survey led to conversations about patient safety and a focus on where pharmacies can make improvements. As a result, some pharmacies introduced a daily communication huddle or a communication record book. These in turn led to improvements in key safety and patient information being shared and disseminated more effectively, while other pharmacy teams improved their data collection around ‘near misses’. This led to a better focus on areas of potential harm and improved training.
The Pharmacy Patient Safety Climate Survey is now available to every community pharmacy team in Scotland through the national pharmacy contract, meaning that people all over Scotland are receiving safer care from their pharmacy.
“We discovered that pharmacies undertaking the Pharmacy Patient Safety Climate Survey led to conversations about patient safety and a focus on where pharmacies can make improvements. As a result, some pharmacies introduced a daily communication huddle or a communication record book. These in turn led to improvements in key safety and patient information being shared and disseminated more effectively.”
This improvement drive was further developed in a large piece of work that I have been involved in this year which has seen the roll out of an NSAIDs Pharmacy Pack.
We knew that there were clear ways to improve care. For example, informing people to take NSAIDs with or after food reduces the risk of gastrointestinal side effects .We knew that earlier recognition by patients of the side effects allows action to be taken before they develop into something more serious. We also knew that raising awareness among patients of the medicine sick day rules can reduce the risk of acute kidney injury, as a result of a dehydrating illness.
To help pharmacies prevent adverse drug reactions, the NSAIDs care bundles were developed into the NSAIDs Pharmacy Pack, which gives clear guidance and improvement resources to help reduce gastric bleeding and acute kidney injury.
Pharmacy staff who are using the pack have reported that they are having better quality conversations with patients, and are informing them of the ‘medicine sick day rules’ which is to stop taking certain medicines if they have a dehydrating illness and restart their medication when they are well again. Before many patients were unaware of this key information. An unintended result of the better quality conversations has been that patients are willing to share additional key information relevant to their health which the pharmacist was previously unaware of, this has the potential to significantly improve the safe delivery of pharmaceutical care.
“To help pharmacies prevent adverse drug reactions, the NSAIDs care bundles were developed into the NSAIDs Pharmacy Pack, which gives clear guidance and improvement resources to help reduce gastric bleeding and acute kidney injury.”
One patient who has been prescribed NSAIDs told us that he had previously had an episode of sickness and became acutely unwell spending several days in hospital due to the reaction of his sickness with his medication. He said: “I was picking up my prescription and the pharmacist gave me a little card, this told me what to do if I had another dehydrating illness. Sometime later, I had another episode of sickness, but I remembered the card. As a heart failure patient you have it drilled into you that you must take your medication, but I followed the instructions on the card and I stopped taking the NSAIDs medication. I then became better. So, that little card made a big difference, to me as I didn’t have to spend days in hospital again.”
The NSAIDs Pharmacy Pack has now been distributed to every community pharmacy in Scotland and is supporting pharmacy teams to provide key safety messages to patients and customers whenever NSAIDs are dispensed or purchased, which will make a real difference to people’s health outcomes.
I’m looking forward to continuing to build on safety work by supporting pharmacists and pharmacy technicians in their improvement journey, and through the development of new models of care in GP practices and through better use of prescribing data, leading to better integration of pharmaceutical care across the primary care sector.
Mark Easton is National Clinical Lead (Pharmacist) at the ihub Primary Care Improvement Portfolio.