A safer approach to hospital pharmacy

In the current austere climate, all clinical teams within the NHS need to demonstrate that they offer value for money and contribute towards the quality, innovation, productivity and prevention agenda. Medicines generate a significant burden of clinical and financial risk for the NHS, but this is particularly the case in secondary care, where medicines are associated with a significant number of clinical incidents and their costs are increasing by around 13 per cent per annum.

For the first time, eight acute hospital trusts in the East Midlands have collaborated to evaluate the contributions to patient care made by clinical pharmacy teams and quantify the associated savings.

The data aggregated by the East Midlands Clinical Pharmacy Network demonstrates that pharmacists and pharmacy technicians make a valuable contribution to the avoidance of “never events”, the achievement of commissioning for Quality and Innovation targets and avoidance of costs associated with medication related errors.

Pharmacists and pharmacy technicians in each hospital recorded their contributions to patient care over a seven day period in November 2010 using a standardised data collection form, Excel spreadsheet and guidance notes. Data capture occurred 24 hours per day for a week, and reflected the variation of different out of hours and weekend pharmacy services operating across the East Midlands.

A “contribution” is defined as when a pharmacist or pharmacy technician has directly contacted a prescriber or nurse to make a recommendation or flag an error.

Categories for data collection included the location of pharmacy staff, the patient’s stage of care, and an outcome measure in terms of whether the contribution was accepted or rejected by the clinician. Contributions were attributed to one of four main types: medicines reconciliation, prescribing, (medicine) administration, or advice/monitoring.

The significance of each contribution was classified as either “major” or “non-major” based upon pre-defined criteria. Essentially, major contributions were defined as those that would have resulted in patient harm within 48 hours, causing permanent or severe patient injury, and prolonging inpatient hospitalisation if the contribution had not been made.

The data was collated at each hospital site and reviewed by senior pharmacists. All major significance contributions were reviewed and validated by the EMCPN to ensure consistent classification across all eight hospitals. The eight trusts reported a collective total of 12,069 contributions over the seven-day period (see chart 1).

By far the most common type of error identified at the medicines reconciliation stage was the “unintentional omission of a medicine”; this represented 68 per cent of all the contributions at this stage. Prescribing a drug unintentionally or prescribing the wrong dose (or frequency) were far less common mistakes identified by the pharmacy teams.

High-risk medicines

Contributions that specifically support compliance with “high-risk” medicines, national targets, CQUINs, patient safety alerts and National Patient Safety Agency guidance were categorised separately. Of the total, 3,409 (28 per cent) of contributions were made in this area (see table 1).

Never events

Commissioners are entitled to recover the cost of the care episode in which a never event occurred, up to a maximum of £10,000 per event. Examples of pharmacy contributions that prevented never events include:

• “An opiate naïve patient prescribed a high strength fentanyl patch post operatively (equivalent to starting a patient on approximately 10 times the normal oral morphine dose). The pharmacist intervened to correct the prescription and ensure the patch was removed.”
• “A patient was prescribed 100mg of morphine instead of the intended 10mg. The pharmacist contacted the prescriber and corrected the prescription.”

Antimicrobial stewardship

Of the total contributions, 1,587 (13 per cent) were made in the areas of ensuring appropriate antimicrobial prescribing. Prudent antimicrobial prescribing is vital to minimising antimicrobial resistance and cases of hospital acquired infections, such as MRSA and C difficile.

CQUIN and quality targets

The safe use of anticoagulants is an important area to ensure patient safety. Targets for veinous thromboembolism risk assessment of patients is a common CQUIN. With clinical pharmacy teams making 882 contributions towards safe “anticoagulant use and VTE prevention” in just seven days, pharmacy staff clearly have an important role to play in maintaining quality of care for patients, as well as securing financial income for trusts.

One example involves a patient with confirmed deep-vein thrombosis who was prescribed a significant underdose of anticoagulant. The doctor was contacted and the correct dose prescribed.

Major contributions

Of the 12,069 contributions, 710 (6 per cent) were classified as being of “major significance” ie they would have resulted in patient harm within 48 hours, causing permanent or severe patient injury if the contribution had not been made. In addition to the examples already given other significant contributions included the correction of:

• Significant overdoses: Phenytoin 300mg TDS instead of 300mg OD Clonazepam prescribed as 60mg /day instead of 1mg, Diclofenac 400mg TDS instead of 50mg TDS,
• X10 errors: Lorazepam 5mg vs 0.5mg, Candesartan 80mg vs 8mg,
• Critical drug omissions Insulin for known diabetics, steroids post transplant.

The School of Health and Related Research at Sheffield University defined the costs related to medication errors (see table 2). EMCPN attempted to assign a financial value to the most significant contributions by working on the assumption that a contribution of major significance in its audit was equivalent to either “potentially lethal” or “potentially serious” in the Sheffield model.

Using a conservative estimate of £1,000 cost avoidance for each major contribution, the 710 major incidences across the region represent a potential £710,000 per week.

Extrapolating this data, EMCPN pharmacy teams make 36,920 major interventions a year, representing a potential cost avoidance of more than £36m.

None of the “non-major” contributions are included in this model, ie adjusting therapy for renal function, pain control, antibiotic course length, unintentional omission of CV drugs, and thyroid replacement.

Prescribing errors occur in all hospital trusts. The EQUIP report - an in-depth study into the causes and prevalence of prescribing errors made by foundation year one doctors - showed prescribing error rates of approximately 9 per cent by junior doctors and confirmed that pharmacists were relied on to identify and correct these errors. Uncorrected, these errors could result in severe or permanent harm for the patient, and associated litigation costs for the trust involved. Pharmacy teams work on the wards and in the dispensaries of most hospitals in the UK and this study demonstrates the significant input these teams have to ensure that prescribing errors do not reach the patient.

This data illustrates that over a year the activity of the pharmacy teams across the EMCPN, by avoiding severe or permanent harm to patients, equates to a potential cost avoidance of nearly £37m. At the very least, these results demonstrate the fundamental role pharmacy teams have in maintaining patient safety.

Over a quarter of all the contributions made are in areas that are a priority for acute trusts. For example, all hospitals have a responsibility to substantially reduce the number of healthcare associated infections. Prudent antimicrobial prescribing forms a major part of this. Input into antimicrobial prescribing was a significant area of input for a majority of all the hospitals involved in this audit.

The results are being used to:

• enhance e-prescribing development and rollout
• inform action plans for recent NPSA alerts
• inform action plans for patient safety initiatives
• develop prevention strategies for “never events”
• Identify discharge blockages (to reduce length of stay)
• Enhance undergraduate and foundation year one training

This is the first time the EMCPN has worked collaboratively to produce data across the region. The project illustrates the value that pharmacy teams bring to acute NHS trusts, both in terms of potential cost avoidance and maintaining the quality of patient care.

Clive Newman is deputy chief pharmacist at Derby Hospitals Foundation Trust and Alison Brailey is principal pharmacist at University Hospitals of Leicester Trust, on behalf of the East Midlands Clinical Pharmacy Network.