Transcript Redland-Hospital-Common-Traps-with-medication-history

Common Traps
with
Sources for Medication Histories
Thanks to the Pharmacy Department for their numerous suggestions
August 2011
Objectives
• To be aware of some advantages and
disadvantages of various BPMH sources
• To be able to avoid common BPMH traps where
interventions are often subsequently made
General Practitioners/Specialists
 Referral letter with list often accompanies patient
 Administration officers can phone & fax request
 Useful for confirming details eg strengths
 What the GP believes the patient takes
 Often incomplete/not up-to-date
 Not necessarily updated/deleted
 Often no directions: ‘MDU’
 Generally records of only 1 GP
 Doesn’t include OTCs/CAMs/non-Rx/specialists
 Often need to cross-reference with patient
GP List:
Just 1 of 3 pages
Community Pharmacies
• Dispensing histories
Administration Officers can phone & fax request
Most Redland patients only use one pharmacy
Will have information about dispensed items additional
to a Webster pack
Compliance: regularity of dispensing, items dispensed
 May not be complete (other pharmacies, GP samples)
 Rx and S4 (label required) items only
 Need to go back in time eg digoxin comes in bottles of
200: may not have dispensed for 7 months
Community nurse & Patient lists
 A list from the ‘source’ (patient/carer)
Generally kept up-to-date by patient/carer
 May only consist of ‘prescribed
medications’/those deemed ‘important’
 Often inaccurate/incomplete/missing doses
• Ensure still up-to-date and fully complete
• Still need to ask other specific questions
eg puffers, patches, eye drops, CAMs…
Previous Admission
 All QH admissions easily accessible via eLMS
 …presuming that nothing has changed
 Verbal changes to discharge medications not communicated
to Pharmacy  no changes made to eLMS
 Patient ceases items due to
misunderstanding/dislike/cost/exhausted discharge supply etc
 GP ceases items
 Items added by patient/GP/specialist/OPD clinic
 Prescribing/dispensing/administration errors
 List may not have been complete on last admission
 Up to 17% of items may be incorrect
 Ensure still up-to-date and fully complete
 The DMR is usually out-of-date the moment the patient leaves
 MUST use as a BASELINE list to build upon
• Charted amiodarone
200mg daily, but
according to DMR
from 5 days ago,
should still be being
loaded with 200mg
bd for 5 more days
Previous D/C (11/2010)
Current admission (5/2011)
Thyroxine 125mcg m
Thyroxine 125mcg m
Omeprazole 20mg m
Omeprazole 20mg m
Aspirin 100mg m
Asprin 100mg m
Frusemide 60mg mmid
Frusemide 80mg m
ISMN SR 120mg m
ISMN SR 120mg n
Coloxyl & Senna 2 bd
Coloxyl & Senna 2-4 n
Paracetamol 1g tds
Paracetamol 1g qid
Cholecalciferol 25mcg m
Cholecalciferol 25mcg m
Temazepam 10mg prn
Temazepam 10mg n
Escitalopram 20mg m
Citalopram 20mg n
OxyContin 20mg bd
OxyContin 5mg bd
Metoprolol 25mg m
Carvedilol 6.25mg bd
Span K 600mg m
Charted on admission
Residential care facility
 Should be an accurate representation of ALL medications
 NB Check for the RIGHT PATIENT!
 ED pharmacist often notes the wrong chart has been sent
 Directions can be ambiguous
 Check for ‘cease date’ – order not necessarily crossed out
 Chart may not be most recent orders
 Check dates
 RNs may give doses from a range eg ‘0-40mg’
 Look at nurse administration section
 More than 1 page of medication list
 Check for eg ‘2 of 2’
 May not correspond with community pharmacy supplies
 Good practice to also request community pharmacy list
 Community pharmacy details located on NH medication charts
Mismatch between NH Chart and Packed Medications
Look for STOP DATES!
Looks as though still prescribed
The need for the second source
• Looks like ‘100 1 bd’
- Charted on admission
• Was originally ‘10mg bd’
• Patient actually
NO LONGER TAKING
- (see cease date)
• Phone call to community
pharmacy confirmed this
Patient’s Own Medications
• DO NOT send home with carer
– Often need to refer back to them during admission
 Many details immediately evident
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Drug/strength/dose
Compliance - # of tablets left vs dispensing dates vs expiry dates
GP/community pharmacy information
Taking other people’s medications/dispensing errors
 Instructions may be out-of-date (refills of old Rx)
 Patient may have brought in other people’s medication
 CHECK NAME carefully & confirm with patient that still taking
 Patient may not bring in all items eg if stored in the fridge
 Contents may not match packaging eg halved tablets
 MUST look inside the bottle
Colour-blind?
• ED pharmacist asked to review the medications for a
warfarin pt with an INR>10
• Warfarin started approx 10 days ago, advised to take
2mg daily
– pt confirmed that he takes 2 brown Marevan tablets daily
• Vit K administered, pt to return next day for another INR
• Pharmacist asked pt to bring all his medications the next
day for review
• The bottle containing 1mg tablets was still sealed and pt
was actually taking 2 pink (5mg) tablets daily
Webster packs
• Can be a double-edged sword
 Back of pack may not match contents
 Patient may not take all of contents eg frusemide
 Patient may take additional items
eg warfarin, patches, puffers, injections
 Some Webster’s wording groups multiple medications
with the same strength together
e.g. aspirin/allopurinol 100mg mane, instead of
creating 2 separate entries for each drug
The danger of Webster packs
Webster Pack
BPMH
Quinapril 10mg m
(NB back of pack states: 20mg)
Quinapril 10mg m
Frusemide 40mg mmid
Frusemide 40mg mmid
Paracetamol 1g qid
Paracetamol 1g qid
Coloxyl & Senna 1 n
Coloxyl & Senna 1 n
Metformin 500mg bd
Metformin 500mg bd
Seretide 250/25 2 bd
Lantus 14 units n
Panadeine Ft prn
WARFARIN
Implies daily dosing
Actual dose = Tues & Fri only
 Front of pack often (BUT NOT ALWAYS) has ‘strange’
doses listed eg bisphosphonates/non-packed items
 Count the tablets
 Call the community pharmacy
 Can also need to check what’s not packed
Patients/carers
 Best when patient’s own medicines are present
 Ask open-ended questions
 Specifically ask about: (see MAP checklist)
 INJECTIONS: Insulin has been previously missed
 Patches/creams/eye drops/inhalers
 Once a week/month
 CAMs
 Non-Rx items…
 Patients may not realise the importance of non-tablets
 Some patients have filled new prescriptions but not
actually started taking
Wording: what’s wrong with this picture?
•
•
•
•
‘What tablets do you take at home?’
‘Avapro – 1 tablet in the morning, right?’
‘Can you please list your medicines for me?’
‘This is what I’m supposed to take…’
• ‘What are you allergic to?’
Thank you!
Questions