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medicines management in NHS hospitals
The Audit Commission promotes the best use of
public money by ensuring the proper stewardship of public
finances and by helping those responsible for public services to
achieve economy, efficiency and effectiveness.
The Commission was established in 1983 to appoint and regulate the external auditors of local authorities in England and Wales. In 1990 its role was extended to include the NHS. In April 2000, the Commission was given additional responsibility for carrying out best value inspections of certain local government services and functions. Today its remit covers more than 13,000 bodies which between them spend nearly £100 billion of public money annually. The Commission operates independently and derives most of its income from the fees charged to audited bodies.
Auditors are appointed from District Audit and private accountancy firms to monitor public expenditure. Auditors were first appointed in the 1840s to inspect the accounts of authorities administering the Poor Law. Audits ensured that safeguards were in place against fraud and corruption and that local rates were being used for the purposes intended. These founding principles remain as relevant today as they were 150 years ago. Public funds need to be used wisely as well as in accordance with the law, so today's auditors have to assess expenditure not just for probity and regularity, but also for value for money. The Commission's value-for-money studies examine public services objectively, often from the users' perspective. Its findings and recommendations are communicated through a wide range of publications and events.
For more information on the work of the Commission, please contact: Sir Andrew Foster, Controller, The Audit Commission,
1 Vincent Square, London SW1P 2PN, Tel: 020 7828 1212
Optimising the use of medicines hospitals is central to the quality of patient care in hospitals.
Expenditure on medicines is rising as new therapies are developed and as more patients are being treated.
Strategic Challenges Hospitals face several challenges in optimising the use of medicines.
Obstacles to Progress and How to In order to meet the strategic challenges presented by the medicines management agenda, hospitals need to elevate the status of some pharmacy services Urgent action and investment are needed in many hospitals to bring medicines management arrangements up to the level of the best.
The Way Forward
5 The NHS Plan
What should trust boards do?
1 Why has this report been
The DoH medicines
Why trust boards should review
medicines management now
3 Linking medicines management
to clinical governance
External advisors and study
Forming effective relationships
with primary care
Obstacles to Progress and
How to Overcome Them
The status of pharmacy services 44
Audit Commission 2001
First published in December 2001 by the Audit Commission for Local Authorities and the National Health Service in England and Wales, 1 Vincent Square, Typeset by Eighteeno4 Design, Woodbridge, Suffolk Printed in the UK for the Audit Commission by Holbrooks Printers, Portsmouth ISBN 1 86240 321 X David Campione/Science Photo Library (cover), Jacky Chapman/Format (pp 3, 7, 8), Steve Horrell/Science Photo Library (p 4), Adam Hart-Davis/Science Photo Library (p 11), Thierry Dosogne/The Image Bank (p 13), Steve McAllister/The Image Bank (pp 36, 47), Steve Taylor/Stone (p 38), David Mansell (p 42), SF/Medipics (p 43), Simon Fraser/Science Photo Library (p 45), Royal Pharmaceutical Society of Great Britain (p 56), Oscar Burriell/Science Photo
The Audit Commission has been responsible for the external audit of
local authorities in England and Wales since 1983, and in 1990 it
assumed responsibility for auditing the NHS. As well as reviewing the
financial accounts of local government and health service bodies, the
Commission's auditors have a statutory duty to examine the economy,
efficiency and effectiveness of the use of resources. The Commission aims
to help those who manage and work in local authorities and the NHS to
deliver the best possible services with the money that is available so that
public expenditure makes the maximum contribution to society.
This report seeks to emphasise to NHS trust boards the importance ofmedicines management as a very significant part of their clinicalgovernance responsibilities. It is one of a number of complementaryinitiatives seeking to raise the profile of medicines management: in 1999, the Department of Health (DoH) introduced the ControlsAssurance Framework, which includes a section devoted to reducingthe risk involved in the use of medicines (Ref. 1); in 2000/01, hospitals in England have assessed their services againstthe DoH's Medicines Management Framework, which has highlightedpriority action areas (Ref. 2); in concert with this exercise, the Audit Commission is currentlycollecting baseline data about medicines management arrangements,which will enable local auditors to work with hospitals, and withchief pharmacists in particular, to improve services; the Audit Commission will work with chief pharmacists' groupsto interpret and analyse these data; and in 2002, the Audit Commission will produce an internet site toprovide guidance on the self-administration of medicines by hospitalpatients.
This report, and the associated audit guide, data collection and training,was prepared by Michael Yeats, Ian Jones, Amy Kerbel, Emma Cox, andNick Mapstone with direction from Jonathan Boyce. A number of individuals have provided support and guidance to the studyteam as the work has developed. They are listed in Appendix 1, togetherwith the organisations visited and the underlying study methodology. TheCommission is very grateful for their contribution though, as always,responsibility for the findings and conclusions of the study rests with theCommission alone.
Optimising the use of medicines hospitals is central to the quality of patient care in hospitals. But many hospitals face significant service pressures that prevent them improving the quality of care given to patients. A hospital patient discusses her medication with the healthcare teamon their ward round. The pharmacist team-member explains proposedchanges to the medication, which the patient will administer herself.
The pharmacist also discusses learning points with other team members. New medication is agreed between members of the clinical team andordered at the bedside though a radio computer link to an automateddispensary, where robotic systems pick the new medicines and dispatchthem to the patient's ward via a pneumatic tube. Computer technology updates the electronic patient record, to which thepatient's GP has access. The medication that has been issued issimultaneously recorded to update stock records and order fresh supplies. The scenario described above is not necessarily a fanciful vision. The best hospitals in the UK are only a few steps away from working like this.
But for many, the vision is a pipe-dream. In these hospitals, many aspectsof medicines management arrangements and practice remain rooted in the1970s. But 30 years ago, the pace of life was slower – the average lengthof stay in hospital was 15 days and bed occupancy ran at 70 per cent.
Today, average lengths of stay are less than seven days; bed occupancy runs at over 95 per cent in some hospitals; patients are more chronicallyill; and are more likely to be transferred between wards. The increasedpace and complexity of work means that the use of medicines is notalways managed to best effect.
Workload pressures are mounting at a time when medicines are becoming ever-more powerful and complex. This means that the risk ofmedication errors is increasing, and there are longer delays in supplyingmedicines. This scenario increases staff stress and turnover, creating adownward spiral that makes significant service improvement a challengetoo far.
Great strides are needed to make medicines management practice in all UK hospitals match the level of the best. A definition of medicinesmanagement illustrates the extensive and inclusive nature of the agenda Medicines management defined
Medicines management in hospitals encompasses the entire way that medicines are selected, procured, delivered, prescribed, administered and reviewed to optimise the contribution that medicines make to producing informed and desired outcomes of patient care.
Source: Audit Commission There are some important obstacles to improving medicines management arrangements: many boards are concerned with short-term financial targets and are many of the specific unwilling or unable to invest money to achieve sustainable qualityand cost improvements; objectives that are set there are serious recruitment and retention problems in some hospital out in the NHS Plan pharmacy services; and Improving Health some pharmacists are content with their traditional dispensing andmonitoring functions – the word ‘pharmacy' conjures up in their minds a room in a hospital, not a patient-centred service where thepharmacist is a key member of the clinical team; and some doctors and nurses have neither the will nor the incentives tochange traditional ways of working.
But the status quo is unsustainable: hospital medication errors are unacceptably common; the efficacy of medicines is increasing, but costs are rising; the complexity of ensuring the safe use of new medicines is growing;and there is an urgent need to review medicines management across wholehealth economies, as the distinction between primary and secondarycare becomes increasingly blurred.
Moreover, improved medicines management underpins many of the specific objectives that are set out in the NHS Plan and Improving Healthin Wales (Refs. 3 and 4). For example, these include: providing new mechanisms to satisfy patients that the care they get isquality assured; reducing the ‘postcode lottery' in the prescribing of anti-cancermedicines; establishing rapid access to chest-pain clinics; ensuring that mental health teams provide an immediate response tocrises; and reducing the number of patients who are dying or being paralysedfrom accidents involving spinal injections.
Why has this report
This report has important strategic recommendations for the DoH and the National Assembly for Wales (the National Assembly). But it is primarily aimed at board members of NHS trusts, and concentrates onthe issues that they have to address. It has two aims: to raise the profile of medicines management in hospitals; and to make the case for providing adequate investment to enablestandards to be raised.
All members of the clinical team need to work together to manage medicines effectively. Non-clinical staff too have to ensure effectivefinancial management, procurement and logistics. But before they cansucceed, there are systemic and resource issues that boards must address.
The strategic challenges facing boards are described, together with the main obstacles and possible solutions. They should use this reportto identify how well their hospital manages medicines, what the mostimportant local priorities are, and how to deliver them.
Expenditure on medicines is rising as new therapies are developed and as more patients are being treated. These cost pressures need to be viewed as part of the overall package of patient care – for some conditions, medicines expenditure should be rising because an increase in spending provides a cost-effective way of increasing health gain for the population. Medicines management is central to the quality of healthcare.
Nearly all patients are given medication as a result of a visit to hospital –7,000 individual doses are administered daily in a ‘typical' hospital; andup to 40 per cent of nurses' time is spent administering medicines. In 1999/2000, NHS hospitals spent over £1.5 billion on medicines, which accounted for 4.6 per cent of their costs. In addition, pharmacystaff cost £300 million a year.
Relative spending on hospital medicines has risen over the last ten years, and in the last five it has outstripped growth in primary care
medicines expenditure [EXHIBIT 1].
Expenditure is rising because: new, more expensive therapies are always being developed; more patients are being treated; the population is ageing and has more chronic illness; and medicines are being used in preference to invasive treatments.
Cash outturn £m
Percentage of total NHS medicines spend by hospitals
NHS expenditure on medicines by
hospitals and its contribution to
total NHS medicines expenditure
Spending on medicines rose sharply over the last ten years, and in the last five years it accounted for a steadily increasing percentage of totalexpenditure on medicines.
1990–91 1991–92 1992–93 1993–94 1994–95 1995–96 1996–97 1997–98 1998–991999–2000 Hospital and community health Hospital spend as a percentage services cash outturn Source: Audit Commission analysis of dataobtained from the DoH There are, of course, differences in the relative amount of money that For some conditions, hospitals spend on medicines. But even after accounting for differences in activity, there remains a significant variation between similar hospitals should be rising in the proportion of their non-pay expenditure on medicines [EXHIBIT 2].
because it would be a It is not known how much of the variation is explained by differences in the age and medical condition of the patients treated because: cost-effective way of hospitals use different descriptions of medicines; increasing health hospitals do not use a common coding system; gain for the medicines are commonly used to treat multiple conditions; and there are no nationally accepted ways of aggregating data to accountfor differences in the age or illness of the patients treated.
What is clear, however, is that some hospitals are experiencing significant increases in their medicines expenditure [EXHIBIT 3]. In recent
years, these cost pressures have been driven by the introduction of new
medicines to treat cancer, heart disease, arthritis, and a range of
psychiatric conditions. In London alone, expenditure on anti-retroviral
medicines for the treatment of AIDS/HIV has risen to £51 million – over
one-sixth of the total expenditure on medicines by London hospitals.
These cost pressures are cause for concern for many trust boards, but they need to be viewed as part of the overall package of patient care. Forsome conditions, medicines expenditure should be rising because it wouldbe a cost-effective way of increasing health gain for the population. Forexample, expenditure on proton pump inhibitors and H2 antagonistsshould be rising because their use improves the quality of patients'lives and saves money by preventing invasive surgery.
Percentage of non-pay spend on medicines
Proportionate expenditure on
There is a two-fold variation between similar trusts' standardisedexpenditure on medicines.
Source: Audit Commission analysis of 1999/2000 TFR3 data Percentage increase in medicines expenditure 1998/99 to 2000/01
Average increases in medicines
expenditure over the last three
Some trusts have experiencedsignificant increases in medicines Source: Audit Commission acute hospitals portfolio data Why trust boards
It is timely for trust boards to review medicines management arrangements because: The DoH's report, An Organisation with a Memory, found that10,000 hospital patients each year have serious adverse reactions to medicines, and one-fifth of clinical negligence litigation stems fromhospital medication errors (Ref. 5). The Chief Medical Officer has settrusts a target to reduce serious medication errors by 40 per centby 2005 (Ref. 6).
Spending on medicines has been identified as a key area forexamination by the government's efficiency task force. In response,the DoH has produced a Medicines Management Framework thatwill be applied to all acute trusts, with reports being made toregional directors of performance review (Ref. 2).
The report of the Task and Finish Group for Prescribing in Walesto the the National Assembly seeks to ‘assure high standards in theclinical care of patients and to enhance professional fulfilment inthose concerned with patients through the prescribing ofmedicines' (Ref. 7).
Medicines management is an important part of the DoH's ControlsAssurance Framework, which seeks to manage risk (Ref. 1).
The recent review of NHS procurement requires all boards to agreea written procurement strategy that includes medicines, as a majorexpenditure item (Ref. 8).
New money was announced in the NHS Plan explicitly to improveIT expertise and capacity (Ref. 3). High priority needs to be given toelectronic patient records and to electronic prescribing, which shouldprovide significant understanding of the effectiveness of medicinesand help to track patients between hospital and primary care. The NHS Plan also states that by 2004 over one-half of the nursingworkforce, together with pharmacists and allied health professionals,will be able to supply medicines (Ref. 3). This is a major change forwhich trust boards need to prepare.
In September 2000, the DoH published Pharmacy in the Future –Implementing the NHS Plan, which set out a programme forpharmacy services (Ref. 9). It says that hospital pharmacists will‘ensure that inpatients' medication is got right early in their stay andthat they have the medicines they need as soon as they are ready tobe discharged.' The National Service Framework for Older People emphasises the
importance of medicines management arrangements (Ref. 10) [BOX B].
National Service Framework for Older People – the relevance of medicines
As people get older, their use of medication tends to increase. Four in 5 people over 75 take at least 1 prescribed medicine, with 36 per cent taking 4 or more medicines (Ref. 11).
The ageing process affects the body's capacity to handle medicines.
Multiple diseases and complicated medication regimes may affect the patients' capacity and ability to manage their own medication regime.
Adverse reactions are implicated in 5 per cent to 17 per cent of hospital admissions of older people (Refs. 12 and 13).
While in hospital, 6 per cent to 17 per cent of older inpatients experience adverse drug reactions (Ref. 14).
As many as 50 per cent of older people do not take their medication as intended (Ref. 15).
Unintentional changes in medication after discharge from hospital happen too frequently (Ref. 16).
There is often poor communication between hospital and primary care and vice-versa. Communication needs to be improved to reduce delay in the transfer of medication recommendations to primary care; to ensure treatment that was only intended as short-term, while in hospital, is discontinued on discharge; and to improve explanations of medication changes. In primary care, the interpretation and actioning of discharge medication histories is not always optimal (Ref. 17).
Older people who are taking four or more medicines have an increased risk of suffering an adverse reaction to a medicine and being readmitted to hospital as a result (Refs. 18 and 19).
The National Service Framework for Older People states that by 2002, all hospitals should have one-stop dispensing or dispensing for discharge schemes and, where appropriate, self-administration schemes for medicines for older people (Ref. 10).
Hospitals face several challenges in optimising the use of medicines. They need to link medicines management to clinical governance and, in particular, introduce processes to reduce risk and the number of medication errors.
Hospitals must also manage medicines across their local health economies and work with commissioners and primary care to improve financial planning.
There are four strategic challenges facing hospitals in relation to linking medicines management to clinical governance; forming effective relationships with primary care; and improving financial planning.
The role of the trust board in medicines
Under the 1999 Health Act, boards must assure the quality of patient care (Ref. 20). Their clinical governance development plans need to containspecific arrangements to implement quality assurance and monitoringmeasures for key activities, such as medicines management. Thesearrangements should supplement and deepen existing professionaland statutory controls.
Shortcomings in medicines management arrangements are evident in many hospitals: Pharmacy services have traditionally established quality controlmechanisms, such as prescription monitoring, but these can fall shortof the ideal – medicines management now needs to be developed tofit into an overall structure for clinical governance.
Only 11 out of 105 hospital consultants surveyed in 4 hospitalsvisited reported that reviews of the use of medicines fed into widerclinical audit work and their clinical governance agendas.
Reviews of board meetings' minutes show that many have notconsidered important aspects of medicines management. A commonresponse is that medicines management is the responsibility of Drugsand Therapeutics Committees (DTCs). However, analysis of theiractivities shows that there are not always systematic reviews of thecost and efficacy of the most significant medicine categories. Individual consultants' clinical freedom still takes precedence overcorporate clinical responsibility, and prescribing practice is seldomreviewed systematically. Only 9 of 105 consultants surveyed reportedthat prescribing practice formed part of their regular performancereview meetings with clinical directors.
Information systems have shortcomings: only 17 of 105 consultantssurveyed felt that they receive adequate information about how theirprescribing practice compares with colleagues in their specialty. Mostdata that are available relate to the cost of medicines, without properconsideration of their efficacy or health outcomes.
These findings suggest that some trust boards are neglecting an important aspect of their clinical governance duties. As a starting point,they should use the DoH's Medicines Management Framework inconjunction with the Audit Commission's diagnostic to monitormedicines management arrangements and develop local action plans [BOX C] (Ref. 2).I
Board-level involvement in medicines management can reduce costs as well as improve quality [CASE STUDY 1, overleaf].
Quality standards and targets for medicines management
Is there effective Relative expenditure changes by BNF formulary chapter Pharmacy service staff numbers, cost and skill mix Is staffing adequate for the services that should be provided? Hospital activity per member of pharmacy staff Does the trust
Costed staff activity in provide an
Amount of time spent on clinical pharmacy Do pharmacy staff devote enough time to direct patient care? Use of original packs introduced processes in line with accepted Use of joint formularies Source: Audit Commission Medicines management is included in the Audit Commission's Acute Hospitals Portfolio –data from all acute trusts on each area referred to in Box C will be collected during2001. The data will be analysed and the results reported to trusts as part of the 2001/02audit programme.
CASE STUDY 1
North Staffordshire Hospitals NHS Trust – medicines management
To encourage all clinical directorates to focus on prescribing issues, a series of reports are presented quarterly to the board. They include a summary table showing the medicine budgets and actual expenditure for the trust as a whole and for each directorate. A narrative reporting the recent decisions of the DTC and the Medicines Management Group, as well as identifying key prescribing issues in each directorate, supplements this financial information. Prescribing is also made a regular feature of performance review meetings between the chief executive and clinical directors.
Better use of medicines has been demonstrated by these actions, and savings have resulted (see Exhibit 11.) Source: Audit Commission study site The role of the Drugs and Therapeutics
.establishing an agreed A process of establishing an agreed formulary is the cornerstone of effective medicines management. There are a number of quality and cost formulary is the consequences if formularies are not developed: cornerstone of greater diversity of prescribing practice resulting in an increased risk of medication errors; higher medicine costs; an increased chance of medicines being out of stock; a greater risk of passing medicine expiry dates; and higher administrative costs because more lines have to be ordered.
An effective DTC will help to ensure that: national and locally agreed treatment guidelines are adhered to; therapeutic categories with high-risk, high-volume or expensivemedicines are regularly reviewed; non-formulary medicines are not routinely stocked; prescribers are monitored for excessive use of non-formularymedicines; the formulary is evaluated periodically for ineffective and obsoletemedicines; and the quality and cost impact of new medicines is always assessed.
In the more progressive hospitals the role of the DTC is developing.
A criticism of the traditional formulary is that it is simply a list ofmedicines: the formulary only becomes a live operational documentonce the medicines are tied to a diagnosis. Chief executives and medical directors should make the DTC at their trust accountable to the trust board for the introduction of evidence-based formularies which are linked to clinical and National Institute forClinical Excellence (NICE) guidelines. These should describe howcommon conditions are to be treated, including the medicines to be used.
To ensure the best treatment for patients, the information is best stored inelectronic format so that it is available at the time that prescribingdecisions are made.
These systems will become more important with the growth of prescribing by nurses and other healthcare professionals. The Governmenthas announced that £10 million has been allocated from 2001 to 2004to train 10,000 nurses (in primary care and in hospitals) to prescribemedicines independently for common conditions in the areas of minorailments, minor injuries, health promotion and palliative care. DTCs also have a strategic role in monitoring prescribing practice.
While detailed analysis is in the domain of clinical audit, the DTC shouldanalyse data on medicines use at an aggregate level, both over time andin comparison to similar hospitals. For example, DTCs might monitoraspects of the hospital's practice with regard to the prescription ofantibiotics, an area where there is wide variation between similar trusts [EXHIBIT 4]. Analysis of this sort could generate reviews of local practice.I
High levels of use of antibiotics may not necessarily be ‘bad' – it could indicate asuccessful policy of discharging those patients who can take antibiotics orally.
Percentage expenditure on oral vs IV antibiotics
Comparison of hospitals'
expenditure on antibiotics
administered orally vs.
There is wide variation betweensimilar trusts in the use of oral vs.
Source: Audit Commission study sites DTCs will increasingly become involved in whole health economy prescribing practice. This development is foreshadowed by the proposalin the Task and Finish Group in Wales that more of DTCs' responsibilitiesshould be devolved to local health groups (LHGs) (Ref. 7). A serious problem?
Linking medicines management to clinical governance will help to assure effective clinical practice, and minimise the risk of medication
errors,I which are an important cause of morbidity in hospitals [BOX D]
(Refs. 21, 22, 23, 24). They account for about one-fifth of deaths due to all types of adverse event in hospital and are also an increasingly common
stimulus to litigation (Ref. 25).II
In the USA, the number of deaths because of medication errors and the adverse effects of medicines used in hospitals increased from 2,876 in
1983 to 7,391 in 1993 (Ref. 24). There is also evidence of an upward trend
in the UK [EXHIBIT 5]). Such trends may be due to the increasing pace of
work in hospitals and to the greater toxicity of modern medicines. During
2001, the DoH has had to publish guidance on preventing medication
errors involving spinal injections, in response to a high profile incident
(Refs. 28 and 29).
Although much of the academic literature on this subject comes from overseas, it is now accepted that these findings can be transferred to theNHS (Ref. 30). It is recognised that medication errors alone cost the NHSabout £500 million a year in additional days spent in hospital (Ref. 6).
However, the true extent of medication errors is unknown because of inadequate definitions and different reporting arrangements. Only onehospital visited had a comprehensive error and near-miss reportingsystem in place.
A medication error may be defined as ‘.any preventable event that may cause or leadto inappropriate medication use or patient harm, while the medication is in the controlof the health care professional, patient, or consumer. Such events may be related toprofessional practice, health care products, procedures, and systems including:prescribing; order communication; product labelling, packaging and nomenclature;compounding; dispensing; distribution; administration; education; monitoring; and use'.
Medical Defence Union data show that one-quarter of all indemnity paid out followinglitigation claims after adverse events in general practice results from medication errors.
Their contribution to adverse events in hospital is not known but is unlikely to be smaller,in view of the scale and complexity of hospital medicines prescribing. Litigation claimscost the NHS £400 million in 1998/99.
Evidence of adverse events in hospitals
From the USA
From the UK
Examples of errors at one hospital
Incidence of iatrogenic disease 10.8 per cent of patients on A patient on the anti-cancer is 4 per cent or 1 million cases medical wards experience an medicine tamoxifen was per year in the USAI
adverse event, 46 per cent of prescribed the sleeping tablet There are four times as many which were judged to be temazepam instead deaths from iatrogenic disease A contraceptive steroid was (180,000 a year) as from road One-third lead to greater prescribed instead of an anti- traffic accidents (45,000) morbidity or death psychotic injection Over 69 per cent of iatrogenic Each event leads to an average A toxic medicine to be given accidents were considered of 8.5 additional days in weekly was prescribed daily An anti-cancer medicine was 20 per cent of adverse events If the data from the sample prescribed at 1,000 times the were related to medicines use trusts are representative and extrapolated across the NHS, this costs the NHS £1.1 billion 12 per cent of adverse events were related to medicines use Source: Ref. 26 Source: Ref. 27 Source: Clinical audit review at one studysite Iatrogenic disease is that caused by a clinician's intervention. Number of deaths
The number of deaths in England
and Wales from medication errors
and the adverse effects of
medicines, 1990 to 2000
The number of reported deaths shows an upward trend.
Medication errors Adverse effects of medicines in therapeutic use Source: ICD9 and ICD10 data The DoH's proposals to address these issues centre upon the establishment of the National Patient Safety Agency. The establishmentof standard nation-wide definitions and categories of medication errorsand ‘near-misses' should be an early priority for the Agency. Trustsshould be required to adopt such systems as part of their clinicalgovernance arrangements and report progress in their annual reports, aswell as reporting along the lines proposed in Building a Safer NHS (Ref. 6).
Following agreement of standard definitions and categories of medication errors, baseline audits should be undertaken with centralfunding at a representative sample of hospitals. This will calibrate thecurrent situation in order that improvement targets can be set and theirachievement monitored. Work should prioritise specialties or areas withthe highest likely risk (for example, ITUs, paediatrics, antibiotics, andnutrition).
The pharmacist's role in reducing medication
Pharmacists have traditionally had an important quality control role in checking patients' medication. Typically, between one-fifth and
one-quarter of inpatient prescription charts are amended by pharmacists
for a variety of reasons that reflect shortcomings in the basic rules for
safe prescribing [EXHIBIT 6].
Nature of errors on medicine charts
identified by pharmacists
Prescription charts are amended by pharmacists for a variety of reasons.
Percentage errors identifed by pharmacists
Type of error
Patient's name incorrect Form of drug incorrect Adverse drug reaction warning Frequency of dose incorrect Administration route incorrect Source: Analysis of data collected from sixhospitals in the Oxford region Concerns have recently been expressed that the core curricula at medical schools do not provide a thorough knowledge of safe medicines
prescribing and administration (Ref. 31). Shortcomings in doctors'
knowledge means that there is a particular risk of medication errors
when they first arrive in hospital. Only a small proportion of new
doctors believe that their induction dealt adequately with medicines
management issues [EXHIBIT 7].
Medication errors are common because of major systemic weaknesses in prescribing arrangements. About 70 per cent of prescribing decisionsare made by house officers and senior house officers even though theyhave little experience of medicines. Studies have also shown that they areprone to increasing error rates when they are stressed, tired, distracted,or are working in unfamiliar surroundings – almost a stereotype ofhospital life (Refs. 32 and 33).
Can medication errors be avoided?
It is important not to under-estimate the task of minimising medication errors. The prescriber has to be knowledgeable enough tochoose an effective treatment that is suitable for the individual patient,taking into account age, infirmity, and possible interactions with othermedicines. Having selected the right medicine and the correct dose, theprescriber has to transmit the message to the dispenser. They then have tohand the medicine to the patient, or to a carer or nurse, who has to seethat the medicine is given in the correct way and at the specified times. Timeliness of advice The perceptions of doctors in
medicines is adequate training of support in medicines
Only a small proportion of doctors in Quality of advice training report that their induction dealt adequately with medicines medicines is adequate management issues.
information about pharmacy services 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of doctors agreeing with the statement
Source: Audit Commission study sites Medication errors occur because of the complexity of this process, but there are several ways in which risk can be minimised: changing the risk management culture; induction and training; redesigning processes and using computer technology to reduceerrors; and developing clinical pharmacy services.
Changing the risk management culture
.senior managers A typical response to errors in hospitals is to identify those involved and castigate them (Ref. 26). The UKCC has recorded its concern that should also seek nurses who made mistakes under pressure of work, and were honest and assurance that actual open about those mistakes to senior staff, have often been subject todisciplinary action. This discourages incident reporting and is potentially clinical practice detrimental to patient care. reflects agreed Hospitals need to learn from the practices of other high-risk industries where risk management concentrates on ‘near misses' as a way ofreducing systemic errors (Ref. 34). The government's view of clinicalgovernance emphasises the need to adopt ‘a systematic approach toquality assurance and improvement . above all, clinical governance isabout changing organisational culture . away from a culture of blameto one of learning so that quality infuses all aspects of the organisation'swork'(Ref. 3).
Trust boards should distinguish between cases where the error is the result of reckless practice and those that have been the result of seriouspressure of work and where an immediate, honest disclosure is made. Allerrors and incidents require thorough and careful investigation that takesfull account of the circumstances and context of the event and theunderlying systemic causes.
Trust boards and senior managers should also seek assurance that actual clinical practice reflects agreed protocols. The recent events atQueen's Medical Centre illustrate how day-to-day pressures can lead toacknowledged best practice being ignored (Ref. 35). There were particularconcerns expressed at some hospitals visited of aseptic preparations beingmade-up on wards, despite protocols stating that they would be preparedin the safer, better quality-assured, facilities in pharmacies. Such practicehas been shown to represent a significant risk to patients because of therisks of microbial and medication errors associated with the preparationof intravenous medicines at ward level (Ref. 36).
Induction and training
Lead clinicians must ensure that all new clinical staff are provided with a formal induction, which should include the provision of guidelinesand protocols covering prescribing practice, medicines administration anderror reporting arrangements. New members of staff should sign toacknowledge receipt and understanding of the guidelines. Inductioncourses should also introduce new clinicians to contact points inthe hospital's pharmacy service. After initial induction, there is a need for continuing training and competency assessments for all clinicians who are involved in theprescription and administration of medicines. No one can prespecifytheir own ignorance, so constant vigilance and a robust safety culturewill always be required to prevent accidents.
Redesigning processes and using computer technology to
Complications arising from medicines treatment are the most common cause of adverse events in hospital patients (Refs. 37 and 38) and
generate adverse publicity for the NHS [BOX E]. Errors may occur from
the initial decision to prescribe to the final administration of the medicine,
and these include choice of the wrong medicine, dose, route, form, and
frequency or time of administration (Refs. 39 and 40).
Most errors are caused by the prescriber not having immediate access to accurate information about either the medicine (its indications,
contraindications,I interactions, therapeutic dose, or side effects); or
the patient (allergies, other medical conditions, or the latest laboratory
results) (Refs. 40, 41 and 42).
Contraindication – any condition that renders a particular line of treatment improper orundesirable.
Examples of adverse publicity involving medication errors
Source: Audit Commission Hand-written prescriptions or patients' notes also contribute to errors as they may be illegible, incomplete, subject to transcription errors or
make use of inappropriate ‘shorthand' [BOX F]. Prescription sheets
themselves may also be temporarily unavailable or lost. To add to the
risk of confusion, different medicines are sometimes contained in
similar packages [BOX G].
Example of patient's notes
Hand-written prescriptions or patients' notes also contribute to errors as they may be illegible, incomplete, subject to transcription errors or may make use of inappropriate ‘shorthand'.
Source: Audit Commission study site Example of different medicines in similar packaging
Different medicines are sometimes contained in similar packages.
The packaging of these medicines is almost the same, but prochlorperazine is an anti-emetic medicine to treat nausea or vertigo; and procyclidine is a medicine for treating Parkinson's disease.
Source: Audit Commission study site Electronic prescribing reduces medicine errors significantly by providing timely, legible information (Refs. 43 and 44). One study concludedthat improved information systems could contribute to the prevention of78 per cent of transcription errors leading to adverse medicine events (Ref. 40). Computerised systems containing rules to prevent incorrect or inappropriate prescribing have also reduced the incidence of errors andincreased the appropriateness of medicine treatment (Refs. 45, 46, 47, 48, 49, 50 The role of clinical pharmacy in reducing risk
Clinical pharmacy applies pharmaceutical expertise to help to maximise medicine efficacy and minimise medicines toxicity in individualpatients. It allows pharmacists to become part of the clinical team and toanticipate medication errors. One of the pharmacist's traditional roles isone of quality control, monitoring and reporting on errors onlyretrospectively. Clinical pharmacy is a move away from re-active qualitycontrol towards pro-active involvement in direct patient care and theanticipation of errors. DoH policy has long recognised the importance of clinical pharmacy in minimising both clinical and financial risk (Ref. 52). Enabling
pharmacists to contribute more fully to patient care reduces patient
morbidity and saves money [BOX H] (Ref. 53). In particular, the presence of
a pharmacist on ward rounds as a full member of the patient care team
reduces prescribing errors significantly (Ref. 54). However, there is wide
variation in the amount of time that hospital pharmacists devote to
clinical pharmacy [EXHIBIT 8].
Analysis of clinical pharmacy services that reduce mortality
Clinical pharmacy service
Number of hospitals
Clinical research Medicines information services Medicines history taken on admission Source: Ref. 53 The ‘p' values refer to associations between a particular pharmacy service being presentand adjusted mortality rates – there is not necessarily a causal link.
Calculated from the difference in death rate/admission (presence or absence of theclinical service) * mean number of admissions/hospital/year offering the clinical service.
Percentage of time spent by registered pharmacists on clinical pharmacy activities
Proportion of time spent on clinical
There is wide variation in the proportion of time that pharmacists devote to clinical pharmacy.
Source: Audit Commission acute hospitalsportfolio data Clinical pharmacy activities should also be extended to pharmacist prescribing and to taking patients' medication histories. There is evidence
that pharmacists are five times more accurate than doctors in writing
discharge prescriptions (Ref. 55). Where it is properly planned and
supported, investment in clinical pharmacy improves the quality of
patient care and reduces costs [CASE STUDY 2] [EXHIBIT 9, overleaf) (Ref. 56).
CASE STUDY 2
North Staffordshire Hospitals NHS Trust – The impact of clinical pharmacy
The medical directorate of the trust, which spends over £1 million annually on medicines, decided to purchase additional pharmaceutical support to provide an experienced clinical pharmacy service to all its wards. Two senior pharmacists were recruited, with the expectation that they would save more than the cost of their salary each year. The initiative has reduced prescribing costs by around 25 per cent through more appropriate prescribing. The greatest savings came from appropriate reductions in poly-pharmacy where patients had been given cocktails of medicines that were designed to overcome the problems caused by other medicines. Source: Audit Commission study site Average cost per script
The impact of the introduction of
The initiative has reduced prescribing costs by around 25 per cent.
Prescribing costs before Prescribing costs after Source: North Staffordshire Hospitals NHS clinical pharmacy clinical pharmacy Trust (Ref. 57). Trusts should undertake reviews of pharmacy staffing levels and consider whether there are adequate resources to: provide all aspects of clinical pharmacy services; meet the demands on pharmacy services of the NHS Plan in respect ofnew consultants and nurse prescribers (Ref. 3); take patients' medication histories; and support dispensing for discharge schemes.
The third strategic challenge facing trusts is to build effective relationships with primary care in order to improve quality and reduce costs across the local health economy. This requires appropriate primary care
joint-working arrangements between primary and secondary care and
progress in four key inter-related areas:
Patients' own medicines
Medication review on admission
Original pack dispensing
Since 1st April 1999, healthcare allocations have been unified across hospital, community health services and general medical services. Thismeans that prescribing costs across health economies are now ultimatelycash-limited. Hospitals now have a vested interest in helping to manageGPs' expenditure on medicines. In the past, there were incentives for hospitals to serve their own .some health limited interests, rather than the NHS as a whole, by passing on the cost authorities have of medicines to primary care. Suppliers traditionally discounted the price of medicines to hospitals in anticipation of recouping their margins fromprimary care.
GP prescribing is greatly influenced by events and decisions taken in pharmacists to hospitals. About 18 per cent of GP prescribing is hospital-initiated; and establish more 40 per cent is strongly influenced by hospitals, since a GP's choices ofmedicines is likely to be guided by local consultants' treatment protocols effective joint (Ref. 58). Many medicines that are prescribed by hospital doctors are continued for some years after discharge. However, three out of four GPssurveyed said that their local hospital did not take account of the impacton primary care when new medicines were introduced.
To tackle these shortcomings, some health authorities have appointed medicines management liaison pharmacists to establish more effectivejoint working between hospitals and primary care groups or trusts(PCG/Ts); or LHGs in Wales. DTCs also have an important liaison role,and should include representatives from commissioners, GPs, PCGs andcommunity pharmacists to co-ordinate policy. Joint-care protocols shouldbe established to manage formularies and the choice of medicines. Theseneed to develop rapidly through the intermediate stage of diseasemanagement guidelines to the eventual objectives of integrated carepathways.
‘Whole system prescribing' arrangements should be examined by all health economies, as there is evidence that this approach improves
prescribing and saves money [CASE STUDY 3].
CASE STUDY 3
Northamptonshire Prescribing Project Group
The Northamptonshire Prescribing Project Group was established at the end of 1999 to advise on prescribing initiatives across the county. The Group comprises representatives from hospitals, PCTs and the health authority.
The Group's work has focused on such issues as therapeutic switching of medicines, introducing branded generic medicines, introducing original pack dispensing and improved information about medicines when patients are discharged from hospital.
The Group has concentrated on agreeing prescribing policies across primary and hospital care, to avoid unnecessary therapeutic ‘switching' of medicines when patients move between sectors.
This work has identified bankable savings of £500,000 (from a total medicines expenditure of £60.3 million) by agreeing protocols on the use of medicines for eight conditions in the last 18 months.
Source: Audit Commission study site Despite such clear benefits, progress with introducing such joint arrangements is patchy, as is shown by the development of joint
formularies [EXHIBIT 10].
Whole system reviews of medicines management practice will also raise fundamental questions about who does what. In particular, thepractice of outpatient dispensing by hospitals should be questioned, andindeed has been challenged by the Report of the Task and Finish Groupfor Prescribing in Wales (Ref. 7). There is a logic that says hospitals should dispense only to those outpatients in immediate need, or where the medication is particularlyspecialised. All other outpatients are their GP's responsibility, with whomthe prescribing decision should reside, with advice following theoutpatient consultation. Such arrangements would eliminate much of theconfusion that is commonly generated when two doctors are prescribingto the same patient.
Patients' own medicines
Trusts usually ask patients to take all their medicines into hospital with them so that an accurate medication record can be made. Patientstake some £90 million worth of GP-prescribed medicines with them intohospital each year – many of these medicines are destroyed or are notreturned when the patient is discharged (Refs. 58, 59 and 60).
If patients' medicines are checked on admission by someone who is properly trained, their suitability for reissue can be assessed and suchwaste can be prevented. Medication should be only designated unsuitablefor re-use if: there is insufficient quantity; the dosage is changed; Progress with introducing
The introduction of joint
A joint formulary covers most The introduction of joint formularies medicines expenditure A joint formulary covers specific groups of patients A joint formulary will be introduced in the next year A joint formulary is under consideration but will not be implemented in the next year A joint formulary will not be considered Source: Audit Commission acute hospitals Number of trusts
portfolio data medicine is stopped; use-by dates have expired; tablets in the container are mixed; there is evidence of physical deterioration; the medicine is inadequately labelled; or the container had no label or batch number.
Observing these basic rules offers a significant quality improvement and requires an early assessment of each patient by a pharmacist. Theyalso empower patients and reduce the confusion and errors that can occurwhen patients receive the same medicines presented and packed in threeor four different ways over the space of a few weeks.
Re-use of patients' own medicines may save money. One study found that 77 per cent of patients' own medicines were suitable for re-use onadmission; and on receipt of the discharge prescription, 56 per cent werere-issued (the balance was not re-issued mainly because the medicationwas stopped) (Ref. 65). An annual saving of £46,000 was achieved. Anotherstudy found that 58 per cent of patients brought some of their medicinesinto hospital with them, of which 60 per cent were suitable for re-use,yielding the potential to save £37,000 a year in one trust.
Medication review on admission
.30 per cent of patients The National Service Framework (NSF) for Older People requires that hospitals put in place systems for medication review on admission to had incorrect or identify medicines-related problems. This is an area where pharmacists have a vital role, either as provider or trainer. At some hospitals visited,30 per cent of patients had incorrect or incomplete medicines or allergies or allergies recorded recorded on admission. This can lead to poorer quality of care, and on admission. longer stays in hospital.
Medication review on admission by a pharmacist can also identify whether an admission is due to prescribing errors or to adverse reactionsto medicines in the community. Medication review on admission can helpto identify such problems and report them back to GPs.
The public needs to be made aware of the importance of taking all medication (including complementary therapies) into hospital so thatpatients' own medicines can be used and accurate medicine historiestaken. National co-ordination of publicity posters to support anawareness campaign would be worthwhile. Self-administration of medicines
Patients should not be The conventional method of giving medicines to patients in hospital is characterised by the use of lumbering drug trolleys on the medicines the passive recipients round. However, the increasing number and complexity of medicines of prescribing means that this system can no longer support safe or efficient medicinesadministration.
decisions by A central theme of both the NHS Plan and Improving Health in Wales is empowering patients to take an active role in managing theirown care (Refs. 3 and 4). Patients should not be the passive recipients ofprescribing decisions by doctors – a shared approach needs to beencouraged whereby patients can learn about and take responsibility fortheir own medication (Ref. 62).
Self-administration in hospital allows patients greater independence and enables them to participate in their own care and make decisionsabout their treatment in partnership with clinical staff. Over 80 per centof the 350 GPs surveyed supported the introduction of self-administrationof medicines by patients in hospital.
Self-administration improves patient compliance with medication regimes and so prevents treatment failure (Refs. 63, 64 and 65). In a study ofpatients with renal failure, 18 per cent did not comply with theirmedication: 96 per cent of those who did not take their medication asrecommended died or had their transplant rejected, compared with18 per cent of the patients who did (Ref. 66). Another study found thatonly one-half of patients took their medication properly once they hadleft hospital (Ref. 67). The failure of patients and clinicians to reachconcordance about medication regimes is a major cause of increasedmorbidity and cost.
Almost all patients who self-administer prefer it because it gives them more control. In one study, over 40 per cent of patients felt moreconfident about taking their medicines when at home, and the samenumber thought that it had increased their understanding – 90 per cent ofself-administering patients knew the purpose of their medicines comparedwith 46 per cent in a control group (Ref. 68).
Self-administration is also beneficial to patients because it: enables the medication to do its job – patients can take analgesicswhen they are in pain, sedation when they want to sleep, and tabletsthat need to be taken before, with or after food, at the correct time; simplifies the medicines regime – many patients, especially olderpatients, have a number of different diseases all requiring differentmedicines. The resulting polypharmacy leads to patients taking manymedicines of doubtful value (Ref. 69). Self-administration leads tosimpler and better medicine regimes because fuller assessment of allthe patient's medication is required (Ref. 70). Simplification improvescompliance with the medication regimen – the rate of non-compliancerises from 15 per cent when patients are asked to take one medicine,to 35 per cent if more than five medicines are prescribed (Ref. 71); allows patients to practise taking medicine under supervision –including opening containers, a serious obstacle for some olderpatients; and alerts healthcare staff to any problems the patient may experiencewith medication.
Improved compliance has quality and cost benefits, particularly by preventing readmission – one-quarter of hospital readmissions are because
of non-compliance with medicines regimes (Ref. 72). However, progress with
implementing self-administration is variable, and there is scope to adopt
more progressive policies in some trusts [EXHIBIT 11].
The main problem associated with introducing self-administration is the initial investment in time and money that is required. Each patientmust have his or her own lockable bedside cupboard at a cost of about£30 each. In view of the likely significant demand for these lockers fromhospitals, the NHS Purchasing and Supply Agency should considerestablishing a national contract.
Investment in staff time is also needed. In hospitals where it has been successfully established, the change process was supported by at least onesenior nurse and one clinical pharmacist was solely allocated to the task.
Once established, self-administration in an average-sized hospital needs tomaintain most of this resource to train new staff, audit performance andensure that there is continuous improvement.
Where such investment is not forthcoming, self-administration schemes invariably fail. Typically, they are left in limbo with the policypractised on some wards, some of the time – a recipe for confusion andincreased risk to patients.
Practice on self-administration
Self-administration of medicines by
Self-administration policies are in place and all patients are encouraged patients in hospital
to self-administer Progress with implementing Self-administration policies are in place self-administration is variable.
but they are applied to limited categories of patients Self-administration will be extended further in the next year Extending self-administration is under consideration, but will not happen in the coming year There are no plans to introduce Source: Audit Commission acute hospitals Number of trusts
portfolio data Original pack dispensing
Closer co-operation across healthcare sectors will promote prescribing and dispensing practice that minimises the cost to the NHS as a whole.
In the last ten years, there has been considerable debate about thequantities of medicines issued to patients when they are discharged.
DoH guidance was that hospitals should provide a minimum of oneweek's worth of medicines to patients on discharge (and two weeks'for outpatients) (Ref. 73). But many regions drew up their own detailedguidelines, and some hospitals reduced the quantity of medicines theydispensed in order to cut costs. Such practice served only to increase overall prescribing costs as hospitals are able to buy some medicines at a substantial discount. It wasalso inconvenient for patients and put an added burden on primary careas each patient had to visit their GP for a repeat prescription, and thenobtain the medicine from a community pharmacist.
Co-operation between primary and secondary care is imperative because of European Community Directive 92/27, which was
incorporated into UK law on 1st January 1999. It requires, among other
things, that all medicines supplied to patients include a patient
information leaflet (PIL) in appropriate lay language; and be labelled with
the product's batch number and expiry date.I The Directive is one of the
key drivers behind the introduction of original pack dispensing, as the
packs contain the leaflets and the expiry date. Most manufacturers supply
tablets and capsules in blister-packs for 28 days' treatment, not in bulk.
Where trusts' current arrangements limit discharge or outpatient dispensing to one or two weeks' supply, they will have to split some packsand risk non-compliance with the law and possible prosecution.
Increasing the dispensed quantity to allow original packs to be used is theonly practical solution. Dispensing medicines to patients in original packs (combined with storing medication at the patient's bedside) has some important benefits, to patients in original and is in compliance with EU regulations: packs has important reduced process costs as medicines are dispensed only once; benefits. greater convenience for patients; reduced GP workload at discharge; reduced overall costs of medicines to the local health economybecause hospital prices are usually lower than those available to GPs; having been issued with 28 days' supply on admission, most patientswill have left at least two (and on average three) weeks' supply whenthey are discharged, so allowing time for GPs to be fully informed ofany problems or changes in treatment before the patient presents fora repeat prescription; reductions in medicine administration error rates (from 9.7 per centto 2.5 per cent at one study site); There is an exemption for hospital inpatients in that whilst the information needs to beavailable, the PIL does not need to be physically supplied to each patient. hospital discharge is less likely to be delayed as medicines are readilyavailable at the patient's bedside; the opportunity for greater use of patients' own medicines as the newsystem is implemented; and fewer interruptions to medical rounds while nurses find medicinesfrom ward stocks.
The savings to individual health economies from introducing original pack dispensing will vary. However, work undertaken at one 1,500-bedtrust estimated an overall saving of £200,000 a year to the local healtheconomy through better procurement. Trusts will need to discuss localimplementation with their health authorities and PCG/Ts, particularlythe transfer of money from primary care to hospitals and theconsequent impact on GP budgets. Patients are missing the quality improvement that can be derived from original pack dispensing because some health authorities, PCTs/LHGs and
hospitals are unable to agree the reallocation of money. Currently, trusts
are not maximising their use of original packs [EXHIBIT 12].
Original pack dispensing means that hospitals take on more responsibility for dispensing medicines that will be taken in thecommunity. This, in turn, is leading some manufacturers to review theirlong-standing practice of discounting the cost of medicines to hospitals(in anticipation of recouping their profits from community sales). Theresultant reduction in price differentiation between the hospital and thecommunity sector highlights the existing anomaly that hospitals have topay VAT on the medicines they buy, while the community sector does not.
The DoH and the National Assembly need to work with HM Customsand Excise to equalise tax treatments between the sectors and removewhat is becoming an obstacle to best prescribing practice.
Number of trusts
The proportion of trusts' total
expenditure on medication
supplied to patients in original
Not all trusts are maximising their use of original packs.
Source: Audit Commission acute hospitals Percentage of total medicines expenditure spent on medicines in original packs
portfolio data The important point about the innovations described above is that they complement each other. Progress is best achieved, therefore, when
they are introduced as part of an integrated strategy [EXHIBIT 13] and
[CASE STUDY 4].
Integrating initiatives in order to
deliver better healthcare for
Initiatives need to be integrated todeliver the greatest benefit.
BETTER HEALTH OUTCOMES
Source: Audit Commission CASE STUDY 4
Redesign of medicines supply services at Mid-Sussex NHS Trust
Medicines supply processes have been re-engineered to enhance the role of pharmacy technicians so that time is released for registered pharmacists to spend on clinical pharmacy and direct patient care. The initiative sought to tackle several problems: prescribing errors were being made when patients were admitted to hospital because of inadequate information (one-quarter of planned patient admissions did not have accurate information from GPs about their current medication); medication and patient selection errors during medicines rounds accounted for over one-quarter of reported medication errors; GPs complained about the poor quality of discharge summaries; one quarter of re-admissions of elderly care patients were known to be due to failures surrounding medication due partly to lack of information sent to GPs on changes in medication during inpatient stays. An audit at Mid-Sussex found that 31 per cent of emergency medical admissions, whose medicines were changed in hospital, reverted to pre-admission therapy within two weeks of discharge when the GP repeat prescribing system was used to continue treatment; waste of inpatient medicines – if a patient moved wards, new medicines were supplied and original medicines destroyed; .costs were offset by CASE STUDY 4 (cont.)
a £60,000 saving from a 50 per cent increase in dispensary workload between 1993 and 1998; using patients' own little control over the timing of dispensary workload.
The trust's aim was to tackle all these problems as part of a ‘whole-system' approach, not on a piecemeal basis. All the initiatives taken were based upon existing good practice elsewhere. The solution
Better use of the skills available
The role of pharmacy technicians has been developed to enable them to assume control of the medicines supply function, thereby releasing registered pharmacists' time to develop their role in: reducing patient risk through active involvement in decision making about medicines use; and identifying and correcting weaknesses in medicines use by improving prescription monitoring and clinical audits.
A senior technician was made responsible for all operational aspects of the dispensary. A registered pharmacist is available, but her role is primarily to: validate any prescriptions that arrive in the dispensary that have not previously been validated by a ward-based pharmacist; deal with clinical issues surrounding prescriptions; and train and mentor technicians in patient counselling.
ii) Re-engineering the ward-based supply process
Supply processes were changed to: use patients' own medication during inpatient stays as the ‘lever' for initiating change; refocus technicians' work on assessing the suitability for use of patients' own medication for use; provide individual de-mountable bedside patient medicines cabinets which ‘followed the patient' during their inpatient stay; supply medicines ready labelled for discharge to cover both inpatient and immediate post-discharge periods; and give GPs and community pharmacists detailed medicines information for patients who had new medication, or who had stopped or changed medicines during their inpatient stay.
There was an increase in costs associated with the initiative: an extra technician was recruited, some existing staff were regraded, and patient lockers were installed. However, these costs were offset by a £60,000 saving from using patients' own medicines, which now account for 10 per cent of items used in the trust. Technicians are now allied with ward-based pharmacists and visit wards on scheduled visits to record details of patients' medication, identifying medication that had been brought in by the patient and medicines that the trust must supply. CASE STUDY 4 (cont.)
The technician's record is used to supply the medicines to cover the inpatient stay and the immediate period after discharge. These enable more control of dispensary workflow and remove periods of excessive activity; and mean that the prescription chart does not leave the ward and remains with the medical record.
Ninety per cent of patients have no change in their medication during the latter stage of their inpatient stay and the initial supply for their discharge is thus ready on the ward for the patient to take home.
The use of lockers has: removed the need to re-supply medicines when a patient moves to speeded up medicines administration rounds; almost eliminated medicine and patient selection errors (only one reported instance on 10 wards in the first 12 months of the initiative); reduced the amount of medicines stored on wards and in the The initiative also aimed to improve the quality of the information about a patient's therapy at admission, during the inpatient stay and upon discharge to GPs. The quality and accuracy of information at admission was improved by having patients' own medicines available for the admitting staff to see. The technicians' ward-prepared medicines sheet provided dispensary staff with a full record of current therapy to refer to when dealing with additional supply requests or other queries about a patient's therapy. Improving the quality of information to GPs on discharge has focused on those groups of patients that are most at risk if their treatment reverts to that in place before admission.
The next steps
The trust is in a good position to implement patient self-medication; patient lockers are in place and nursing staff have welcomed the fact that medicine administration rounds are now quicker. The more effective use of pharmacists' time also means more resources are available to train nurses in facilitating self-administration. The need to shift resources from non-pay to pay budgets to fund The need to work across the whole health economy; and The need to adopt innovation that is tried and tested, and supported by research evidence.
The fourth strategic challenge for trust boards is to provide effective financial planning and control.
Current annual budgeting arrangements
In many hospitals, finance directors find it impossible to produce a balanced budget with the money available at the start of the year. Most
hospitals therefore overspend their medicines budgets [EXHIBIT 14]. In many
cases, finance directors have to rely on slippage from other budgets to
offset the overspend on medicines.
When original budgets are constantly overspent in this way, it is a sure sign that the original budget was wrong. Medicines cost pressures
are now being made more explicit through the work of NICE, and some
trusts are working across the health economy to identify the full extent
and necessary funding of future costs pressures [CASE STUDY 5, overleaf].
Many of the proposals contained in this report require an initial investment to improve the quality of medicines management and reducethe costs of medication errors. A characteristic of trusts that haveachieved significant progress is the willingness of the trust to transfermoney from non-pay to pay budgets. For example, investment in clinicalpharmacy services needs initial funding, but a good clinical pharmacistwill save his or her salary in the same financial year.
Number of trusts
Comparison of trusts' outturn
expenditure on medicines and
One in three trusts overspent their2000/01 medicines budgets by more than 10 per cent.
11% to 15% 16% to 20% 21% to 25% Percentage overspend 2000/01 (original budget vs. outturn)
Source: Audit Commission acute hospitalsportfolio data CASE STUDY 5
Identifying future medicines cost pressures
To improve annual budget-setting at Salford Hospitals, directorate pharmacists and their clinical colleagues prepare an assessment of future medicines cost pressures and develop a planned approach to the introduction of new medicines in consultation with health authorities and local PCG/Ts. The assessment identifies existing medicines that have an identified change in use or a change in clinical practice that will generate future cost pressures. Arrangements for in-year cost pressures are agreed between commissioners and providers on the basis of ‘shared- Example of medicines cost pressures 2000/01 – Salford Hospitals NHS Trust
HARD TO AVOID
Microbial resistance IV Administration Pre-made syringes/minibags EL(97)52 DVT and PE Homecare Low molecular weight heparins to reduce bed stay Trigeminal Neuralgia Anaemia in dialysis Erythropoietin – virement Ribavirin and Interferon alpha PCTA/stent medicines Clopidogrel – Cardiology PCTA/stent medicines Abciximab – Cardiology Glycoprotein iib/iiia blockers – NICE guidance Chimeric monoclonal antibodies Muscle relaxation Total IV anaesthesia Specialist medicines Mirena – unlicensed use Premature infants Palivizumab – prevention of RSV Urology – CA bladder BCG for irrigation Source: Salford Hospitals NHS Trust Procurement
Pharmacists need to. A number of regional contracts for medicines between the NHS Purchasing and Supply Agency (PASA) (and its predecessors) and work closely with PASA suppliers has long been established. These cover about 60 per cent of and the procurement product lines and seek to aggregate NHS purchasing power.
professionals in their However, regional contracts have, to some extent, been weakened by hospitals renegotiating them in order to gain short-term price advantage.
trusts to develop Suppliers have in all probability anticipated the likelihood of local re-negotiations when making tender offers to the NHS. with key suppliers. A Ministerial letter sent to trusts in January 2001 makes clear the Government's view about procurement in England. It wants: procurement and supplies issues are to be considered regularly bytrust boards; more of trusts' non-pay expenditure, including medicines, are to becovered in a cohesive strategy; and a united NHS front presented to suppliers – contracts established bythe PASA should be adhered to, not ignored or re-negotiated.
For medicines that are not covered by regional contracts, pharmacists in both English and Welsh trusts have a strong track-record of working inconsortia, using their purchasing power and commitment to contractvolume to reduce prices.
100. However, while prices are strongly controlled, there is patchy
performance in other aspects of supply: hospitals in London are currentlyexperiencing particularly poor performance from wholesalers in terms oflate deliveries and partially-filled orders, although in Wales wholesalerperformance is much better. Across the country, there are also fewexamples of the use of consignment stocks or of using suppliers to helpwith management information on performance and use. 101. Pharmacists need to build on their procurement expertise and work
closely with PASA and the procurement professionals in their trusts todevelop strategic partnerships with key suppliers. These arrangementsshould seek to ensure that both buyers and sellers work together to takeadvantage of the significant opportunities that exist to reduce process andtransaction costs in the whole medicines supply chain.
102. Greater use of technology would also reduce process costs. Work by
PASA has found that moving from manual to electronic updating ofcontract details in hospitals reduces the time taken for this task from20 staff days a year to two.
103. Both the Association of the British Pharmaceutical Industry and PASA
are aware of the opportunities to improve service standards and reducetotal supply chain costs, and should work with trusts to deliver them.
104. However, as previously noted, it is not known how much of the
variation in prescribing activity between hospitals is explained bydifferences in the age and medical condition of the patients treated. Thecurrent absence of any arrangement to aggregate local data associatedwith prescribing, purchasing and supplying medicines to a national levelwill limit the effectiveness of NHS procurement in general and thepotential benefits offered by e-commerce in particular.
Obstacles to Progress and How to
In order to meet the strategic challenges presented by the medicines management agenda, hospitals need to elevate the status of some pharmacy services to focus their attention on patient care, address staff recruitment and retention problems, and invest in computer technology to reduce risk to patients.
105. Three main obstacles need to be overcome in order to meet the
strategic challenges that are described in the previous chapter. They are: the current low status of some hospital pharmacy services; staff recruitment and retention problems; and the need to introduce computer technology.
106. The importance of the pharmacist's role needs greater recognition
The status of
outside the profession, especially at board level; and sometimes within the Attitudes outside the profession
107. Research evidence that supports innovation is overwhelming in areas
pro-active care on admission; re-engineering supply through the use of original pack dispensing; medication review clinics; better use of pharmacy technicians; development of pro-active clinical pharmacy services; self-administration of medicines by patients; pharmacist prescribing; and the use of IT and automation.
108. But not enough trust boards have acted on this evidence and
.trust boards often considered sufficiently the link between medicines management and appoint new consultants effective clinical governance. without reference to 109. There is also a tendency to regard pharmacy merely as another
support service, rather than one that is absolutely vital to the quality of the effect that their patient care. For example, trust boards often appoint new consultants without reference to the effect that their additional workload will have onpharmacy services. will have on pharmacy 110. At the hospitals visited, auditors reviewed the background papers
making the case to trust boards for the appointment of consultants, but inonly one case out of twenty was there explicit reference to the impact thatthe new consultant would have on the demand for pharmacy services.
111. The NHS is seeking to recruit 7,500 new consultants and 20,000
nurses as part of the NHS Plan (Ref. 3). It is important that boards makeprovision for the impact that they will have on pharmacy services.
112. Medicines management is so vital to the quality of patient care that
its status, and the status of hospital chief pharmacists, need to bereviewed in many hospitals. At the hospitals visited, greatest progress indelivering the strategic challenges outlined in this report had beenachieved where the head of the pharmacy service held a positionequivalent to that of a clinical director.
113. The introduction of directors of pharmacy would also open up greater
career opportunities further down the organisational hierarchy and wouldhelp to reverse the exodus of pharmacists from the hospital service.
Attitudes within the profession
114. Attitudes also need to change within the profession. In some
pharmacy services, there is an inherent conservatism and a need to‘market' pharmacy positively to senior management. If trusts are tooptimise the use of medicines, pharmacy needs to be a core clinicalfunction. 115. Excellent pharmacy services are characterised by:
a chief pharmacist with the necessary strategic vision and politicalskills to ensure that pharmacy services are given due prominence withits key ‘customers'; pharmacists with the necessary skills of persuasion and negotiation, tomanage working relationships with their clinical colleagues; and recognition by the trust board that pharmacy is first and foremost aclinical service.
116. The introduction of the four-year master's degree for pharmacists will
improve the quality of clinical education, but developing management andinfluencing skills also needs attention, both at a professional level andthrough on-the-job training and coaching. 117. The Royal Pharmaceutical Society of Great Britain (RPSGB) also has
a major role to play in equipping a new generation of pharmacists forenhanced clinical and managerial roles. The Society therefore shouldreview the adequacy of its current support for hospital pharmacists'education and training; continuing professional development; professionalcompetence and performance; and its workforce planning arrangements.
118. The number of hospital pharmacy staff has increased by 25 per cent
in the last five years. Most of the increase is due to a growth in pharmacy
technicians [EXHIBIT 15].
119. Despite these increases, 15 per cent of pharmacy posts are still
vacant.I One-half of the hospitals in the UK are unable to provide all their
intended pharmacy services because of staff shortages (Ref. 74). Overcoming
these shortages in the short-term is unlikely – supply has been curtailed
by increasing the length of pharmacy undergraduate courses to four years.
In 2000/01, there were very few new pharmacy graduates going on to
take their pre-registration training year, so in 2001/02 there will be very
few newly qualified pharmacists.
120. The effect of these continued shortages is exacerbated by growing
demand for pharmacy staff: demand for pharmacists from outside the hospital sector; increases in demand from traditional workload areas; increases in demand from new services; and the need to increase pharmacy operating hours.
Demand for pharmacists from outside the hospital sector
121. Demand for pharmacists has been increased by the requirement that
all PCG/Ts or LHGs have a pharmaceutical adviser. There is also demandfrom private sector pharmacies, particularly the supermarket chains, someof whom are able to attract pharmacists because of better pay andconditions. National hospital pharmacy vacancy survey 1999, conducted by the NHS PharmacyEducation and Development Committee. WTE staff numbers
Whole time equivalent staff
employed in hospital pharmacies
The number of hospital pharmacystaff has increased by about 25 percent in the last five years.
Headcount at 30 September
Source: Audit Commission analysis of data supplied by the DoH Increases in demand from traditional service areas
122. The number of inpatient episodes has increased by about 10 per cent
in the last five years, and the number of prescriptions written per patienthas also increased. This has had an effect on traditional pharmacyservices, such as dispensing.
Demand from new services
123. Workload pressures also stem from the demand to extend
pharmacists' clinical roles (Ref. 75). For example, in outpatient services,there are demands for pharmacists to run anticoagulant clinics andtherapeutic drug monitoring clinics. Pharmacists are also assumingresponsibility for managing inpatient anticoagulation and aspects of doseadjustment for some shared care medicines.
124. Supplying medicines under patient group directions, as set out in the
NHS Plan, will enhance the role of pharmacists in the multi-disciplinaryclinical team, both as trainers and as clinicians (Ref. 3). Studies have shownthat pharmacist involvement produces benefits in patient outcomes,improves the quality of doctors' prescribing and saves money (Ref. 76). Aswell as taking these steps, trusts should anticipate possible changes to theMedicines Act that will allow pharmacists to act as full independentprescribers.
125. Schemes such as pharmacist prescribing will force pharmacists away
from their traditional, re-active model of prescription review to adopting
a more pro-active role. Currently, pharmacists spend a significant amount
of time annotating patients' prescription charts. However, these
interventions take place, on average, 48 hours after the patient has been
given their medication [EXHIBIT 16] (Ref. 77). Since some errors are potentially
life-threatening, it is clear that a pro-active approach would be safer for
patients. However, introducing pro-active rather than re-active pharmacy
services will place further demands on pharmacists' time.
Category of error
Average time between prescription
and identification/correction of a
There are significant delays betweenprescription errors and intervention.
Average hours between prescription and intervention
Source: Ref. 77 126. On all fronts, pharmacy services should be asked to provide a more
.an extension of service pro-active approach. Prescriptions should be reviewed on or as soon after hours is unavoidable if admission as possible; reviews of patients' own medicines are needed; and hospitals are to deliver there is a growing demand for pharmacy involvement in dischargeplanning (Ref. 78).
all aspects of 127. The clinical role of pharmacists will further increase with the likely
growth of pharmacist prescribing (expected following the provisions of the 2001 Health and Social Care Act) (Ref. 79).
128. The quality of patient care and cost-effectiveness of medicines use can
be achieved by enhancing the role of the clinical pharmacist in the multi-disciplinary team. Enhancing their role would also reduce the workloadof doctors in training. Such schemes have been found to improve thequality of doctors' prescribing, as well as saving money (Ref. 80).
The need to extend pharmacy operating hours
129. Finally, workload demands are placed on pharmacy services by the
need to move away from the traditional model of a 9 to 5, Monday toFriday service. 130. Extending the pharmacy service's operating hours makes sense given
the time of day when prescriptions are written. Up to one-half of
inpatient prescriptions are written outside the traditional 9 to 5 weekday
working hours [EXHIBIT 17]; over the weekend, 77 per cent of
prescriptions are written outside the traditional three-hour Saturday
service (9am–12 noon) (Ref. 81). Thus, an extension of service hours is
unavoidable if hospitals are to deliver all aspects of pharmaceutical care
uniformly to all patients.
131. Moving to a 24-hour, seven days a week service would be impractical
in most hospitals on cost grounds. However, extending ward-basedservices into the early evening and at weekends appears logical.
132. The pattern of hospital work also means that adequate arrangements
must be in place for on-call medicines information services. Theopportunities afforded by computer technology should enable more ofthese services to be provided off-site and out of hours in order tominimise cost.
The time of day that prescriptions are written
Prescriptions are written around the clock.
Number of items dispensed
Pharmacy open Pharmacy closed Time of day
Discharge medication Source: Audit Commission (surveys from four study sites, based on the research model in ref. 81) Tackling staff shortages
133. Trusts can tackle staff shortages by investing a sustained effort in the
introducing more flexible working patterns; re-engineering pharmacy services; redesigning and enriching jobs; introducing automation; providing administrative support; and reviewing make or buy decisions.
Introducing more flexible working patterns
134. Some trusts need to offer more attractive remuneration packages and
flexible working conditions to attract and retain pharmacists. Womenmake up 68 per cent of the pharmacy workforce and 70 per cent of themare under 40 years old (Ref. 82). Delivering the NHS's Improved WorkingLives Directive is highly important to meet their needs (Ref. 83).
Re-engineering pharmacy services
135. The principal objective of a re-engineered service is to put pharmacists
closer to patients as this is where they add the greatest value. Trusts
should review the tasks that are being undertaken by pharmacists with a
view to ensuring that this objective is met, while activities like dispensing
are automated. Revision and expansion of the pharmacy technician and
pharmacy assistant roles need to play a major part in this strategy,
provided that proper competency assessments are established and adhered
to [BOX I].
136. The role of the pharmacy technician is now so pivotal to hospital
pharmacy services that the RPSGB should consider the formal registrationof pharmacy technicians.
Job design and enrichment
137. Studies of staff turnover have found that there is wide and
unexplained variation in turnover between trusts in similar geographiclocations (Ref. 84). Although local and national economic factors play theirpart, more than one-half of the variation is explained by differences inthe way that trusts manage their staff. At the trusts visited, it was notablethat while most reported recruitment and retention problems, those atthe leading edge of medicines management practice reported that theirservices were not adversely affected by recruitment and retentionproblems. Main roles in pharmacy services
Pharmacists' key roles
Pharmacy technicians' key roles
Regular top-up service to wards Prescribing (once the provisions Clinical pharmacy services of the Health & Social Care Act within agreed guidelines Dispensary and aseptic support Procurement of medicines Services that could be supported by
Clinical governance All aspects of supply and non-pharmacy staff
Preparing guidelines of clinical dispensing of medicines Business planning Educating for concordance Performance management Checking patients' own Some aspects of procurement Reviewing whole health Pharmacy assistant key roles
Services that could be supported by
economy prescribing Supply of medicines – inpatient Running certain clinics and stock dispensing (with Medicines information services checking by a pharmacy 138. Enriching the work of technicians is particularly important if staff are
to be retained. Some pharmacy services make extensive use of pharmacytechnicians to undertake work that was hitherto the preserve of registeredstaff, such as procurement, supply and dispensing functions. Universitycourses are also now available to train technicians in clinical pharmacyroles.
Robotic systems release 139. Staff can also be released through automated dispensing. Robotic
systems release staff for patient-centred services, and reduce dispensing staff for patient-centred errors [CASE STUDY 6] (Ref. 85).
services, and reduce 140. Few trusts are likely to have the capital or the expertise to invest in
these systems, and there seems little sense in trusts individually specifyingdifferent systems. Economy of scale, and standardisation of systems andbarcodes, could be achieved if the DoH and the National Assemblyjointly commissioned a national specification for automated dispensing.
The provision of earmarked funds to roll-out the introduction of thesesystems to all large acute hospitals might also be considered in light of theimprovements they offer.
CASE STUDY 6
Wirral Hospitals NHS Trust's robotic dispensing system
Wirral Hospital installed a robotic dispensing system in January 2001, at a cost of £300,000. The business case was approved by the board on the grounds that the system would reduce dispensing error rates and release staff to manage medicines at ward level.
Items are bar-coded and selected for dispensing via remote terminals. The systems covers 77 per cent of medicines items, handling mainly items in whole containers.
The system dispenses between 900 and 1,200 items each day.
The benefits of the system include: dispensary turnaround times have been reduced; reported dispensing errors reduced from 19 per 100,000 to 7 per ordering processes are simplified; improved reliability of service; more efficient use of staff – three whole time equivalent pharmacy technicians have been released to support direct patient care; reduced staff down time; potential use of consignment stocking; 70 per cent less shelving needed; and floor space required has been reduced by one-half.
141. Some managerial and administrative tasks that are undertaken by
qualified pharmacists could be undertaken equally well by non-clinicalstaff. General managers and administrative staff should be used for tasksthat they can perform, such as business planning, performance review anddata management.
Make or buy decisions
142. The DoH's Controls Assurance Standards for Medicines Management
acknowledges that aseptic dispensing is an increasing and demandingactivity for pharmacy services (Ref. 1). Some NHS manufacturing capacityis also needed to provide medicines that are not commercially available.
However, boards should always consider whether collaboration withother trusts for the provision of common aseptically prepared items andmanufacturing is a viable alternative to individual trusts investing in theseservices. Such collaboration may be a way to release pharmacy staff andcapital for investment in other activities.
143. Computerised prescribing linked with electronic health records will
radically alter the way in which care is provided and will deliversignificant improvements in the quality of patient care (Ref. 86). Theintroduction of these systems, which ultimately need to be accessible byprimary care and other hospitals, is vital to provide access to commonclinical data. It is one of the biggest challenges currently facing the NHS.
144. The Information for Health strategy expects 35 per cent of trusts to
have installed electronic patient record systems (including the reporting ofresults and prescribing) by 2002, and all trusts by 2005 (Ref. 87). Thestrategy provided £60 million (about £600,000 for an average healthauthority) to which a further £250 million is provided in the NHS Plan.
However, the funds are not ringfenced, so some trusts have spent lessbecause of competing priorities and deficits, and generally progress isextremely slow. 145. These systems have been introduced in only a few hospitals. Two
trusts that have introduced them successfully share a number of common
attributes [CASE STUDY 7].
CASE STUDY 7
Introducing electronic patient records – Burton on Trent Hospitals and Wirral Hospitals
and are therefore more prepared Providing the capacity to deliver
A major source of risk and to take managerial risk. The sheer avoidable costs in hospitals stems size and organisational complexity Both organisations created from inadequate patient records.
of the larger teaching trusts may managerial slack to invest in the Patient care is jeopardised by make informal networking and change process. Both projects were inaccurate, illegible or lost paper commitment building difficult.
led by small, multidisciplinary records; professionals' time is There was extraordinary stability in project boards of 5 or 6 individuals.
wasted and errors in diagnosis and key personnel at both trusts. Wirral Large, representative working treatment are made because kept the same chief executive and parties were avoided. The project accurate information is not chief pharmacist throughout the boards were professionally-led, not available at the time decisions are 1990s; Burton also had the same dominated by finance or technical chief pharmacist, and promoted The technology to deliver electronic their medical director into the chief Change takes time
patient records (EPR) in hospitals executive's post when it became There was an acceptance in both has been around for more than 10 vacant. Both retained the same organisations that change would years but few hospitals have been core of lead consultants. This take a significant amount of time successful in managing the changes consistency is regarded as vital in because the work involved re- that are necessary to implement maintaining direction and ensuring engineering the way that doctors, high priority for EPR nurses and other clinicians work.
The procurement processes alone took two years. This commitment at Both EPR projects were pump- board level helped to insulate the Unlike most NHS trusts, Burton and primed with additional ear-marked change processes from competing Wirral have avoided significant funds – Wirral was a first wave, and organisational change over the last Burton a second wave Resource 10 years – there has been no Management Initiative site.
significant merger activity.
Both projects had clear milestones, ‘Marketing' the system objectives
breaking the project down into Both trusts have a comparative manageable pieces. Both trusts organisational simplicity – both are In both trusts, the systems were rolled their projects out on to geographically isolated with clear designed and ‘marketed' to wards where they expected the catchment populations, referral improve the process of patient care, most support from the staff lines into primary care and links not to save money. The benefits involved, and both were willing to with their health authorities. This were described in terms of reduced retreat and retrench in the face of has created an environment that to patient risk and improved clinical some extent insulates both trusts audit. Although there are from ‘politicisation', competition secondary financial benefits, and some would say outside through reduced process costs and Both trusts (perhaps by virtue of better use of medicines, these the ‘scientific' management style of benefits were never seen as central Both trusts are of a manageable doctors and pharmacists) collected to either project. This approach size. Some hold the view that baseline data on key indicators to helped to ensure professional change is easier in organisations of demonstrate benefits and calibrate this scale, because senior people the success of the new systems.
can ‘see across the organisation' Data included measuring (reduced) CASE STUDY 7 (cont.)
medication errors, speed of test delivered – once paper systems are results, discharge delays, and abandoned there is no ‘going back.' On the evidence of this case study, additional time spent with patients.
This places a premium (and cost) on the key ingredients that lead to Collecting the baseline data helped training new staff. Temporary staff success in implementing EPR are: to maintain commitment to the – particularly locum doctors – are staff and organisational projects at board level, and to unable to work without full demonstrate their value in the face training in the systems. Potential insulating the change process; of competing priorities.
new consultants are asked to confirm at interview that they accepting that change takes Making change stick
would work with EPRs and EP, and Introducing EPR and electronic are not appointed if they are collecting data to calibrate prescribing (EP) radically changes the way that patient care is 146. Computer technology is not an optional extra but a fundamental part
of the modernisation agenda on which to build other changes required bythe NHS Plan and Improving Health in Wales, including theimplementation of effective clinical governance (Refs. 3 and 4). Technology isalso the way to release scarce pharmacy resources into direct patient care Percentage of total time
How pharmacists' time is spent
Pharmacists in trusts with automated dispensing and electronic prescribingsystems are able to devote more time to direct patient care.
With automated automated dispensing and electronic prescribing Clinical activity Travelling from pharmacy to wards Supply of medicines Prescription monitoring and adaptation Source: Ref 92 147. Achieving the targets that are set out in the Information Management
and Technology (IM and T) strategy in respect of electronic healthrecords and electronic prescribing systems is a tall order given the currentstate of development in most trusts (Ref. 88). Only one in three executivedirectors surveyed said that their trusts had clear plans to introduce thesesystems. On current progress it is likely that less than 10 per cent of trustswill meet the 2005 deadline.
148. Urgent action is needed to put the IM and T strategy back on course.
A standard national system for coding medicines across the NHS isrequired to support the introduction of electronic prescribing andelectronic health records. Earmarked funds and expertise should beconsidered, as well as central guidance on systems specifications, screenlayouts and coding structures. Such a centralised approach would preventunnecessary duplication of effort, provide economy of scale inprocurement and would make working with the NHS in this area a moreattractive proposition to suppliers of IT and software systems.
Urgent action is needed 149. As well as the significant cost of the computers and software, the
introduction of new systems will fundamentally alter the way that to put the IM and T doctors, nurses and pharmacists work together to deliver patient care.
strategy back Many trusts will need support and guidance in the organisationaldevelopment aspects of introducing these new technologies. on course. 150. The cost of introducing IT and software to deliver electronic health
records and electronic prescribing systems to a typical hospital is in theregion of £2 million, with £500,000 annual running costs. Much of themoney needed is already available in the provisions of the IM and Tstrategy, and its investment would be recouped quickly by eliminating alarge proportion of the £500 million spent each year on treating patientswho are harmed by medication errors and adverse reactions.
151. A strongly centralised strategy runs directly counter to the
government's philosophy of decentralisation, expressed in Shifting theBalance of Power within the NHS (Ref. 89). Nevertheless, it is an optionthat merits urgent and serious consideration. The Way Forward
Urgent action and investment are needed in many hospitals to bring medicines management arrangements up to the level of the best. The risks of not acting are substantial, both in terms of the quality of patient care and the costs to the NHS. Maintaining the status quo is not a viable option.
The NHS Plan
152. The main principles that underpin the NHS Plan are to:
re-shape care around the patient; improve quality; and make better use of NHS staff.
153. Pharmacy in the Future – Implementing the NHS Plan covers issues
that are relevant to medicines management (Ref. 9). It envisages some
radical shifts in job design [BOX J] and support for medicines management
Principal responsibilities in medicines management implied by the NHS Plan
NEW MODEL (?)
Diagnose disease state Supply the therapy Nurses (under guidelines) Administer the therapy The relevance of the NHS Plan to medicines management
NHS PLAN COMMITMENT
RELEVANCE TO MEDICINES MANAGEMENT
The ‘expert patient' programme will be Argues for greater use of patients' own medicines; and extended – NICE will publish patient-friendly versions of clinical guidelines Breaking down the barriers between staff Qualified nurses, midwives, therapists and pharmacists will (£10m for increased nurse prescribing) be empowered to undertake a broader range of clinical tasks, including for some prescribing medicines and for the majority supplying medicines under Patient Group Directions Integrated electronic patient records are very important to improving the quality of medicines management services – for example, improving links across healthcare organisations £140m to ensure that all professional staff are Presents an opportunity to increase the skills of supported in keeping their skills up-to-date and administrative staff and technicians and so release to provide access to learning for all NHS staff pharmacists for professional work without a professional qualification £30m to boost childcare One-half of all hospital pharmacists are women. Family-friendly policies would ease recruitment and retention problems What should trust
154. Action is required on several fronts to deliver better medicines
management. The DoH has much to do in delivering the agenda set out in boards do?
Building a Safer NHS for Patients, and the IM and T strategy (Refs. 6 and 88).
The pharmaceutical supply industry, too, should also be taking a morepro-active role: it shares the same interests as the NHS in ensuring theefficacy of medicines; in eliminating unnecessary supply-chain costs; andin improving patients' compliance with medication.
155. But this report has been mainly about what trust boards must do. It is
important not to underestimate the scale of the task that they face indelivering the agenda that is described in this report. This is not through alack of desire or interest but due to the time and staff required to leadand implement the changes. .trust boards will need 156. The list of recommendations provides a challenging agenda for
change. A systematic approach needs to be taken by each trust. They need to invest in computer to compare their current position against the recommendations of this systems and automation report, then prioritise actions, plan, and monitor the outcomes. It is adaunting agenda, where a significant investment of money and effort is in order to release needed to secure progress. But the risks of not acting are substantial, both pharmacy staff in terms of the quality of patient care and the costs to the NHS.
resources into direct 157. In particular, trust boards will need to invest in computer systems and
automation in order to release pharmacy staff resources into direct patient services. patient services. Investment in training and development will also beneeded to increase the knowledge base in order to provide comprehensiveclinical pharmacy services.
The DoH medicines
158. The DoH has emphasised its commitment to the importance of
medicines management through the dissemination of its framework. The framework will indicate to trust boards where progress is needed locally in the following areas: senior management commitment; financial control; policy on the use of medicines; primary care interface; prescribing influence; and risk management.
159. A preliminary review of the framework returns suggests that, of the
seven areas, senior management commitment is the one where significantimprovement is needed.
160. Over the coming months, returns from the medicines management
framework will be analysed in conjunction with returns to the AuditCommission's acute hospitals portfolio. The DoH should consider usingthis exercise to enable identification of Beacon Sites for medicinesmanagement. These trusts should then be funded to run open days thatare aimed at board members. Dissemination of good practice in this wayneeds to be encouraged. A mechanism to make readily available advice,guidance and the experience of achieving the goals stated in this reportwould be beneficial to trusts. Local audits
161. The Commission has collected quantitative data about acute
hospitals' medicines management arrangements. Where analysis highlightsshortcomings, the Commission's auditors will recommend in-depthreviews as part of their performance management audit. Auditors willthen tailor the findings and recommendations of this report to localcircumstances. 162. Local audits will supplement the DoH initiative and generate much-
needed attention to raising the profile of medicines management. Alltrusts and health authorities should consider auditors' recommendationsin the context of their overall responsibilities for clinical governance. The terminology used in these recommendations is aimed at England; however, they are broadly consistent with the recommendations that are made in the the National Assembly's Report of the Task and Finish Group on Prescribing (Ref. 7).
For the Department of Health and the National Assembly for Wales
The establishment of standard nation-wide definitions and categories of 1 medication errors and ‘near-misses' should be an early priority for the new National Patient Safety Agency. Trusts should be required to adopt such systems as part of their clinical governance arrangements and should report progress in their annual reports, as well as reporting along the lines proposed in Building a Safer NHS (Ref. 6).
Following agreement of standard definitions and categories of medication 2 errors, base-line audits should be undertaken with central funding at a representative sample of hospitals to calibrate the current situation in order that improvement targets can be set and their achievement monitored. Work should prioritise specialties with the highest likely risk. National co-ordination of publicity posters should be considered to encourage 3 patients to take their medicines into hospital with them. The DoH and the National Assembly need to work with HM Customs and Excise 4 to equalise tax treatments between hospital and community sectors and thus remove what is becoming an obstacle to best prescribing practice. The DoH and the National Assembly should commission a specification for 5 automated dispensary systems and consider the provision of earmarked funds to roll-out the introduction of these systems to all trusts. A standard national system for the coding of medicines and barcodes should be 6 introduced across the whole of the NHS to support the development of electronic prescribing systems and automated dispensing systems. (Paragraphs 140 and 148) Earmarked funds should be made available to enable trusts to comply with the 7 targets that are set in the NHS IM and T strategy (Ref. 88). Central guidance on systems specification and screen layouts should be considered. Trusts' medicines management framework returns should be analysed in 8 conjunction with returns to the Audit Commission's acute hospitals portfolio. The DoH and the National Assembly should consider using this exercise to enable the identification of Beacon Sites for medicines management. These trusts should then be funded to run open days aimed at board members. For the Royal Pharmaceutical Society of Great Britain
The RPSGB should review the adequacy of its current support for hospital 9 pharmacists' education and training; continuing professional development; professional competence and performance; and its workforce planning The RPSGB should consider introducing the formal registration of pharmacy For the NHS Purchasing and Supply Agency
PASA should consider establishing a national contract for the supply of patients' 11 medicines lockers. (Paragraph 80).
PASA should work with trusts and with the Association of the British 12 Pharmaceutical Industry to examine and eliminate supply chain costs and improve wholesaler and supplier performance where necessary. (Paragraphs 101 to 103) For NHS trust boards
Trust boards should use the DoH's Medicines Management Framework in 13 conjunction with the Audit Commission's diagnostic to review medicines management arrangements and develop local action plans (Ref. 2). Medicines formularies should be agreed that are linked to joint care 14 arrangements, clinical guidelines and NICE guidance. Medicines management groups and DTCs should be made formally accountable 15 to the trust board or to the clinical governance committee. Risk management arrangements should be reviewed and ‘fair blame' and ‘near 16 miss' reporting systems introduced. (Paragraphs 44 to 45) Trust boards and senior managers should seek regular assurance that actual 17 clinical practice reflects agreed protocols – in particular, the practice of making- up aseptic preparations on hospital wards should be stopped. Lead clinicians should ensure that the induction programme of all clinical staff 18 provides adequate coverage of policies on prescribing practice, medicines administration and incident reporting. Monitoring of competencies in prescription and administration of medicines should be given high priority.
(Paragraphs 47 and 48) Trusts should undertake reviews of pharmacy staffing levels and consider 19 whether there are adequate resources to: (i) provide for all aspects of clinical pharmacy services; (ii) meet the demands of the NHS Plan in respect of new consultants and nurse (iii) take patients' medication histories; and (iv) support dispensing for discharge schemes. (Paragraphs 56 and 132) Arrangements should be introduced for the use of patients' own medicines in (Paragraphs 68 to 69) Trust boards should call for a position statement on progress towards introducing 21 self-administration of medicines and providing the necessary staff resource to maximise implementation. (Paragraphs 72 to 82) Original pack dispensing should be introduced in all appropriate areas 22 immediately, using Department of Health guidance. Re-packaging of medicines from bulk should be stopped, wherever possible. (Paragraphs 85 to 88) The annual Service and Financial Framework round should include an assessment 23 of future cost pressures from medicines, and a risk-sharing approach agreed between commissioners and providers. (Paragraph 94 and Case study 5) Transfer of money from non-pay to pay budgets should be considered in order to 24 fund investment in pharmacy services. Wherever possible, trusts should use PASA contracts for medicines. 25 (Paragraphs 96 to 98) Pharmacists should work with procurement professionals in the development of 26 strategic partnerships with the main suppliers. Trusts should introduce electronic updating of supplier contract details.
27 (Paragraph 102) Trust boards should always consider the impact on pharmacy services when 28 appointing new consultants. (Paragraph 111).
The role of chief pharmacist should be elevated to the equivalent of a clinical 29 director and should be a member of the trust's management executive.
A review of pharmacy operating hours should be undertaken. 30 (Paragraph 130) Recruitment and retention policies and practice should be reviewed to provide 31 competitive working flexibilities and remuneration packages for pharmacists.
Primary and secondary care should work together to consider limiting the 32 practice of outpatient dispensing. (Paragraphs 64 and 65) Original pack dispensing should be introduced immediately. 33 (Paragraphs 95 to 97) Appendix 1
Addenbrooke's Hospital Association of the British Pharmaceutical Industry Airedale Hospitals and Health Authority Birmingham Children's Hospital Centre for Practice and Policy, School of Pharmacy,University of London Blackpool Victoria Hospitals Department of Health Burton Hospitals Glaxo, SmithKline Cardiothoracic Centre, Liverpool National Prescribing Centre East Riding NHS Trust and Health Authority NHS Purchasing and Supply Agency George Eliot Hospital Royal College of Nursing Guy's and St Thomas's Royal Pharmaceutical Society of Great Britain John Radcliffe Hospital, Kettering Hospital Manchester Children's Hospital Mid-Sussex NHS Trust Milton Keynes Hospitals North Birmingham Mental Health Trust North Cheshire Hospitals North Staffordshire Hospitals Northumbria Healthcare Plymouth Hospitals Salford Hospitals South Warwickshire General Hospitals United Lincolnshire NHS Trust University Hospital of Wales Regional meetings of chief pharmacists in Wales, WestMidlands, South-East and London regions Appendix 2
The following individuals have supported the study team with advice and Sue Ashwell
Kettering Hospitals NHS Trust Derbyshire Royal Infirmary NHS Trust Keith Farrar
Wirral Hospitals NHS Trust John Farrell
Department of Health North Staffordshire NHS Trust Royal Salford Hospitals NHS Trust Department of Health Deputy Chief Pharmacist, Department of Health Queen's Medical Centre, Nottingham Royal Pharmaceutical Society of Great Britain Mike Pollard
North East Wales NHS Trust Keith Ridge
Department of Health University Hospital of Wales David Scott
John Radcliffe Hospital, Oxford Chelsea and Westminster Hospital NHS Trust Wirral Hospitals NHS Trust Mike Spencer
University Hospital of Wales Vic Standing
North Western Regional Pharmaceutical Advisor NHS Purchasing and Supply Agency Debra Walker
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Pharmaceutical Journal, 1993, 251:356 60. Dobrzanski S, Reidy F, The pharmacist as a discharge medication planner in surgical patients. Pharmaceutical Journal, 1993; HS53–HS56 61. Campbell D et al, Waste not, want not, Health Service Journal, 24 August 62. HSC 2000/01:LAC (2001) Intermediate Care, Department of Health, 63. Lowe C et al, Effects of self-medication programme on knowledge of drugs and compliance with treatment in elderly patients, British MedicalJournal, 1995; 310:1229–1231 64. Wood SI, Calvert RT, Acomb C, Kay EA, A self-medication scheme for elderly patients improves compliance with their medication regimens.
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8, 19, 23, 90, 140, 154, 160 controls assurance framework Complementary therapies Adverse reactions to Controls Assurance Standards Computer technology Box B (p12), for Medicines Management Box D (p19) guidance on preventing centralised strategy medication errors Ageing population 14; Box B (p12) medicines management Anti-coagulant clinics Drug monitoring clinics appointment by trust boards 109–11 Anti-retroviral medicines Drugs and Therapeutics clinical freedom Committees (DTCs) impact on demand for Case Study 1 (p16) pharmacy services influence on GP prescribing Aseptic preparations Association of the British reviews of prescribing practice Pharmaceutical Industry Cost discounts on medicines Efficacy of medicines 6, 22, 26, 53, 154 Audit Commission Electronic patient records (EPR) Automated dispensing Costs of medicines 143, 144, 147, 148, 150; Box I (p50) management 11–9 Case Study 7 (pp53–4) 107, 135, 139–40, 157 Electronic prescribing (EP) computer technology 52, 147, 148, 150; consequences of undeveloped Case Study 7 (pp53–4) future medicines cost pressures Case Study 5 (p40) European Community Case Study 6 (p51) Information for Health strategy 144 Beacon Sites for medicines litigation claims Expiry dates of medicines medicines for patients on discharge 83–4, Case Study 4 (pp36–8) recent increases savings from original pack Building a Safer NHS for Patients Financial planning dispensing 87–8 current annual budgeting savings from re-use of patients' arrangements 93–5 Case Study 7 (pp53–4) future costs pressures systematic reviews overspending on medicines variations between hospitals procurement of medicines 9, 96–104 Box D (p19) Financial targets Chest pain clinics Definition of medicines Flexible working patterns Chief Medical Officer Box A (p5) evidence-based 28 Delays in supplying medicines Future developments in Clinical governance Dispensing errors Case Study 6 (p51) medicines management approach to quality assurance role in medicines Doctors' prescribing management 21–32, Clinical negligence litigation caused by doctors' NHS Purchasing and Supply inexperience 39–40 80, 96, 98, 101–3 caused by inadequate agenda for change Health and Social Care Act 2001 Case Study 4 (pp36–8) need to review medicines caused by unsatisfactory management arrangements prescriptions or patients' HM Customs and Excise Box F (p24) role in medicines management 21–4, definitions and categories strategic challenges DoH guidance on prevention Iatrogenic disease Box D (p19) 32–5; Box D (p19) Non-clinical staff Importance of medicines improvement targets Non-formulary medicines management in healthcare investigation of North Staffordshire Hospitals Improved Working Lives Case Study 1 (p16), pharmacist's role in reducing Case Study 2 (p27) reduced by electronic prescribing 52 Improving Health in Wales Northamptonshire Prescribing Case Study 3 (p29) Medication histories Induction and training Medication regimes medicines supplied by Information for Health strategy Case Study 4 (pp36–8) Medication review on admission Information Management and mistakes made by Technology (IM and T) strategy 147, training in prescribing Information systems Mental health teams Intravenous medicines Mid-Sussex NHS Trust Case Study 4 (pp36–8) 19, 107, 147–50 Obstacles to improving medicines Monitoring of medicines management arrangements Organisation with a Memory, Morbidity in hospitals Job design and enrichment Box H (p26) 153; Box J (p57) Original pack dispensing Multiple conditions 16; Box B (p12) 107; Case Study 3 (p29) Joint working arrangements role of liaison pharmacists limits of supply National Assembly for Wales Outdated medicines management Length of stay in hospital National Institute for Clinical Excellence (NICE) Outpatient dispensing Litigation claims costs Box K (p57) Local audits of medicines National Patient Safety Agency management 161–2 National Service Framework Local health authorities (LHGs) 31, 61, Packaging of medicines for Older People 19, 70; Box B (p12) Box G (p25) 7, 74, 124, 146, 152–62 Patient information leaflet (PIL) action by trust boards DoH medicines management Patients' own medicines Make or buy decisions framework 158–60 savings from re-use of Medication errors 3, 5–7, 19, 25, 32–56 Case Study 4 (pp36–8) 152; Box J (p57) cause of adverse publicity for relevance to medicines Box E (p23) Box K (p57) Pharmaceutical supply industry Primary care groups (PCGs) Robotic dispensing and trusts (PCTs) Case Study 6 (p51) Procurement of medicines 19, 96–104, Royal Pharmaceutical Society of education and training Great Britain (RPSGB) exodus from hospital service electronic updating of contract four-year master's degree Government's view as key members of clinical 5, 53-4, 124, 128; late deliveries and partially-filled Salford Hospitals Case Study 5 (p40) Box I (p50) Self-administration of liaison role between hospitals 57, 73–82, 107; and primary care regional contracts Case Study 4 (pp36–8) 55, 107, 125, 127; strategic partnerships with benefits to patients Case Study 2 (p27) failures of some schemes united NHS front to suppliers investment in time and money quality control role wholesaler performance role in medical review on Proton pump inhibitors for older people Box B (p12) Psychiatric conditions women pharmacists Senior management commitment 158, Pharmacy assistants 135; Box I (p50) Shifting the Balance of Power Pharmacy in the Future – within the NHS (DoH) Implementing the NHS Quality assurance 7, 21, 22, 25, 38, Shortcomings in medicines management arrangements Pharmacy operating hours Quality of healthcare Spinal injections Pharmacy technicians Quality standards and targets for medicines management Case Study 4 (pp36–8); Box C (p15) Staffing 118–51 Box I (p50) automation 139–40 Queen's Medical Centre, Polypharmacy 78; Case Study 2 (p27) computer technology Postcode lottery demand from new services Prescribing practice demand for pharmacists outside for hospital patients on Readmission to hospital discharge 83–4, extension of pharmacy Case Study 4 (pp36–8) Recent trends in medicines variations between hospitals management 11–8 increase in hospital pharmacy Prescription monitoring Review of medicines management increased demand from traditional service areas costs passed from hospitals job design and enrichment integrating initiatives changing the culture make or buy decisions joint working arrangements induction and training managerial support with secondary care minimising medication errors need for flexible working medication review on admission 70–2 pharmacist's role in reducing original pack dispensing medication errors re-engineering of pharmacy patients' own medicines redesigning processes services 135–6; Box I (p50) Case Study 4 (pp36–8) role of clinical pharmacy in recruitment and retention and secondary care 6, 20, 57–82, 85; Box B (p12) seriousness of problem reviews of levels by trusts self-administration of use of computer technology to medicines 73–82 vacancies in pharmacy services variations in turnover Status of pharmacy services attitudes outside the profession 107–13 attitudes within the profession a clinical service conservatism in pharmacy hospital chief pharmacists Task and Finish Group in Wales 19, 31, Toxicity of medicines Traditional ways of working Box D (p19) VAT on medicines 8, 19, 90, 100, 140 Whole system prescribing arrangements 62, Case Study 3 (p29) Wirral Hospitals NHS Trust Case Study 6 (p51), Case Study 7 (pp53–4) Workload pressures 3, 33, 44, 109, 123 The Audit Commission has produced a number of reports covering related issues.
Acute Hospital Portfolio Goods for your Health Review of National Findings
Improving Supplies Management in
for Day Surgery
This review, the fourth in a new series
The proper management of supplies is
from the Audit Commission, summarises
vital to the smooth running of NHS trusts.
the results from the Commission's national
Moreover, substantial amounts of money
survey of all day surgery units in England
are involved: a typical trust spends
and Wales. It examines current day
between one-fifth and one-quarter of its
surgery performance, the progress made
annual revenue expenditure on supplies.
since the Commission's last review in 1998,
The results of this study indicate that
and the scope for further improvement in
better management could release at least
the management and use of day
£150 million over the next three years.
Goods for your Health makes
2001, ISBN 1862403139, £10, stock code HNR2594 recommendations as to how this can be
National Report, 1996, ISBN 1862400024, £15, stock code HNR1170 Education, Training and
Development for Healthcare
Acute Hospital Portfolio Staff in NHS Trusts
This report explores the methods that
Review of National Findings for
trusts can adopt to help them to
Accident and Emergency Services
proactively manage education, training
The second report in the Audit
and development for their staff, from
Commission's Acute Hospital Portfolio
creating an organisation-wide training
series reviews the national findings of the
and learning culture, through to setting
Audit Commission's survey on A&E
up effective support systems to make it
services. It compares waiting times across
a reality. The study focuses on nurses,
departments and against national
midwives, health visitors, allied health
standards. It also examines the workloads
professionals, scientific and technical
of nurses and doctors.
staff and healthcare staff without a
2001, ISBN 1862403090, £10, stock code HNR1877 professional qualification.
National Report, 2001, ISBN 1862402701, £20, stock code HNR1519 To order further copies, or a full catalogue of Audit Commission Publications, please
contact Audit Commission Publications, PO Box 99, Wetherby, LS23 7JA.
Telephone 0800 502030.
A SPOONFUL OF SUGAR
Medicines management in hospitals encompasses the entire way in which medicines are selected, procured, delivered, prescribed, administered and reviewed in order to optimise the contribution that medicines make to producing informed and desired outcomes of patient care. Managing the way that medicines are used in hospitals is the business of all clinical staff and it directly affects most patients. It is a strategic issue fundamental to the way that hospitals work, to the quality of patient care and to the delivery of the NHS Plan and Improving Health in Wales This report sets out a number of recommendations to help to optimise the use of medicines. The Department of Health and the National Assembly for Wales have important leadership roles to play in supporting new technology and providing a framework for risk management. But there is much that hospitals must do, both in terms of placing medicines management at the heart of their clinical governance responsibilities, and by introducing innovations that are accepted good practice. Patients too have a central part to play – at present only one-half of them take their medicines as recommended by their doctor.
Further copies are available from:
The report will be of interest to patients, to all healthcare Audit Commission Publications, professionals who work in hospitals, to executive and TIONAL REPOR
non-executive board members, to service commissioners, Telephone: 0800 502030
policy makers, and to the supply industry.
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Audit Commission1 Vincent Square, London SW1P 2PNTelephone: 020 7828 1212 Fax: 020 7976 6187www.audit-commission.gov.uk
Comparison of ebastine to cetirizine in seasonal allergic rhinitis in adultsPierre Gehanno, MD*; Clothilde Bremard-Oury, MD†; and Philippe Zeisser, MD† Background: Second-generation histamine H1-receptor antagonists are accepted antagonist with no anticholinergic or first-line systemic therapy for seasonal allergic rhinitis. Ebastine is a new histamine
Case ReportJ Vet Intern Med 2011;25:1166–1170 F.A. Wininger, R. Zeng, G.S. Johnson, M.L. Katz, G.C. Johnson, W.W. Bush, J.M. Jarboe, An 8-year-old female spayed Bernese Mountain Dog sociation with a protein concentration of 30mg/dL and (BMD) presented to the Bush Veterinary Neurology no nucleated cells. Magnetic resonance imaging of the Service (BVNS) for paraparesis. The dog had been seen