Ensuring Patient Safety: Are We Doing Everything Possible?

Patient safety has always been on the pharmacist’s agenda. Every dispensed medicine carries with it a whole set of checks to ensure that the patient gets medicines safely.

A case in point: oral methotrexate—safety checks include the following:

  • Providing patients with information before and during treatment
  • Ensuring dispensing software is updated to include the latest methotrexate alerts and prompts
  • Ensuring purchased products comply with recommendations

Findings from secondary care

All patients receiving oral methotrexate should carry a monitoring and dosage record. The UK CPA is exploring the best way to develop national reporting amongst community pharmacists. Lessons can be drawn from findings from secondary care. The National Reporting and Learning Scheme (NRLS) data include all patient safety incidents, of which about 6% relate to medicines.

Data are comparable with other studies around the world, which concluded that about 8% of medication errors occur during prescribing, 14% during dispensing and 35% at administration. Of dispensing errors, 22% were wrong doses, 21% wrong medicine and 7% wrong patient.

Drugs which are error-prone are similar in the US and the UK: insulin, heparin/warfarin, and morphine are generally among the top 10.

What does it mean for community pharmacists?

Some pharmacies are already collecting dispensing error data and this is an important resource. However, community pharmacists also can be a source of information on prescribing errors, administration errors (yes, by patients, as that is how the majority of medicines are administered).

How data will be collected and reported nationally is yet to be decided. Meanwhile, pharmacists can do the following:

  • Look at high-risk drugs and see if additional safeguards can be set up
  • Report problems with product packaging or labeling, either identified by yourselves or by patients
  • Review dispensing processes
  • Identify weak areas and build in safety steps such as checks, prompts, and reminders

Above all, be prepared to share your findings as it is through shared learning that true error-proofed systems can be devised.



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Preventing Harm to Patients: 4 Different Ways to Put the Right “Barrier”

Understanding and implementing safer systems of work can reduce the risk to patients. We are all looking for safer systems of work and often we put in place what seems like a good preventive step, maybe following on from an incident. There are a number of ways to ensure you are putting in the right “barrier”, and ways of ensuring it is will do what you are expecting it to.


4 types of barriers

Barriers can be grouped into four types:

  1. Human action – checking a drug dose prior to administration
  2. Administrative barriers – training, supervision, and procedures
  3. Physical – protective equipment/storage
  4. Natural – place time or distance

In practice, the easiest barriers to put in place are the human actions, but it is easy to see then why mistakes keep occurring. Barriers can be evaluated as being strong average or weak to counter a hazard. Any barrier involving human action is marked down.

Administrative barriers are only as good as their promulgation and need to be current and constantly reinforced.

Physical barriers are harder to implement as they require investment and often add in a time factor.

Natural barriers can again cause delay and are therefore often overlooked as cumbersome, but if you look at the measures recommended for safer use of potassium solutions, it is the physical separation of potassium, the requirement to treat it differently that makes the barrier effective. Recommendations for intrathecal chemo also uses “time” and separation (“place”) barriers to counter the hazard.


How to evaluate barriers

Barrier analysis can be used retrospectively when an incident has occurred, or prospectively, as part of a risk assessment strategy. A useful tool. Have a go.

Anyone interested in patient safety should look out the DoH/Design Council report – Design for Patient Safety. This is a document that is eye catching and makes a good read.

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Why Pharmacists Need to be Trained in Nutrition: The Fields Where Nutrition can be Applied

Why are there many pharmacists who aren’t involved in nutrition? When we were pharmacy students, we learned about protein, carbohydrates, fats, and fluids. Why not apply that knowledge in the treatment of patients?


Catabolic disease treatment

Catabolic patients burn amino acids for fuel, yet we want them to build protein to have the strength to get out of the hospital and recover from surgery or acute illness in the comfort of their own homes. Excess fats are bad for healthy people, but at 9kCal/g, you can’t beat it as an isotonic source of energy in the critically ill.


Diabetes treatment

Pharmacists need to understand the role of carbohydrates in diabetic patients. Good blood sugar control post-MI has been shown to improve outcome by 30%. In septic shock, it improves outcome by 40%. This is more cost-effective than thrombolytics or activated protein C.

The unique contributions of a pharmacist (formulation knowledge, incompatibility experience, and skill in managing interactions)—it’s all in nutrition! Choosing the most appropriate formulation for a tube-fed patient can be challenging; who else the pharmacist knows what is available? What tablets can you crush, what can you substitute to get the same therapeutic effect; these are questions for pharmacists to answer.



And then there’s nutraceuticals. The enteral feed can do more than just feed patients. Immune-modulating feeds contain arginine, purine nucleosides, and omega-3 fatty acids to enhance white blood cell function yet suppress inflammation. This has been shown to reduce the length of stay, improve outcome, and reduce treatment costs.


Intensive care and cancer treatment

Intensive care and cancer patients often receive multiple antibiotics. This, in turn, selects out resistant organisms. Pharmacists should be involved in decisions to give more potent antibiotics or think laterally about alternative options. Have you considered lactobacillus capsules? This is an area worth exploring. Coordinate with the dieticians about the transfer of parenteral nutrition to enteral. That’s a team working, and it’s rewarding for staff and patients.

So who says pharmacists can’t be trained to manage nutrition? Pharmacy and nutrition should always go hand in hand when treating patients.

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