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Safe use and recording of medicines in the community (Drivers (Healthier…
Safe use and recording of medicines in the community
Drivers
AWMSG
NG67
Healthier Wales
Care closer to home
Independence
Inappropriate use of MDS
Medicines safety
Medicines Waste
Prudent Health Care
No consistent pathway for medicine support
Lack of person centred care
National Guiding Principles for Medicines Support in the Domiciliary Care Sector
Challanges
Different needs of DN and paid carers
What do they administer?
Paid Carers
Role of paid carers not consistant across Wales
District Nurse
Mainly administer items that are outside the scope of practice of paid care workers.
Warfarin and insulin don’t necessarily fit as they tend not to have prescriptive directions on the prescription. Therefore I don’t see how the MAR alone will cover this. Hence our going down the route of separate charts for these.
There will be the odd patients who needed to have their whole medicines list administered but that would be rare.
Role of paid carers not consistant across Wales
How would regular but not daily meds be charted such as Vit B 12 and Prostap (12 weekly meds?) on a MAR chart
may potentially further add burden as the chart authorisation to administer would run out after each injection. (monthly MAR charts)
Where do they obtain chart?
District Nurse
Transcribing policy
Where woud this happen - ? at the hub as referrals for administration are received
Need a robust system for medicines reconcilliation - ? not all DN’s have access to GP systems
Need to ensure they have sight of the prescription to transcribe from
Who will re write the charts at the end of the month?
many of the nursing community are not happy with the RPS and RCN guidelines which they deem as inadequate from a nursing perspective
All Wales standards being developed
Local medicines management policies differ?
? Need to review all HB policies
district nursing teams’ policy that requires a medication chart to be signed by a prescriber, before they can administer medication
GP
Officially - no need for a GP to complete a MAR Chart - a prescription is all
that is legally required for a nurse or other community worker to administer medication.
Community Pharmacy
What happens when meds are generated in secondary care that need to be administered in the community
Simiar issues to paid carers
No MAR chart - Just record administration in patients notes.
Paid carers
Community Pharmacy will supply
Lack of consistency
Funding
Only ABHUB, Hywel Dda, ABM have a scheme
Chief Pharm officer supporting of an All Wales scheme
Charts
Number of different types of pre-printed chart available. No evidence on safety or effectivnress of different types
The use of MAR chart are recommended in guidelines e.g. NICE, but there is no legal requirments for care providers to use them (some providers record in patient notes)
Domcare agency will produce
? Appropriateness
Role of the GP
Dissatisfaction with All Wales Hosp med charts - not fit for community, inc risk of errors with having to rewrite charts more often, increased DN & GP time being taken to get charts rewritten, etc.
General feedback - If no progress is made GP’s may stop completing these charts (apart from maybe palliative care/syringe drivers/insulin).
district nursing teams’ policy that requires a medication chart to be signed by a prescriber, before they can administer medication
Supported by BMA
"We are still having frequent requests for charts which is, as I explained below, needless and incredibly timewasting"
"For example today, I was interrupted in the middle of a very busy on-call clinic to re-write an insulin administration chart – complete waste of time for me and the nurse, and doing things in a rush like that is how mistakes and patient harm occurs. THIS IS NOT SAFE!"
Role of Pharmacy
Enhanced service
Only ABHUB, Hywel Dda, ABM have a scheme
Current scheme not fit for purpose for national role out.
Based on duplicate dispensing stickers being added to a blank chart
Doesn't satisfy most Pharmacy SOPS
The situation with the current service is far from ideal, and the development of PMR templates capable of producing fully populated MAR charts that could be printed by the pharmacy is a much better solution in the longer term (and safer).
Scotland National MAR Chart
PMR Suppliers in Wales
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PMR Suppliers in Scotland
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Potential to adopt in Wales
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As a complicating factor, in rural areas patients choose to access their medication via a dispensing GP practice, who use very different software to pharmacies, but are still able to participate in the existing label based MAR chart service.
Unfortunately neither of the two main GP systems, Vision and Emis can print MAR charts – and colleagues are not clear if this functionality is in the pipeline for upgrades
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Community Pharmacy can only print A4 chart and in black and white
The health board MAR charts are A3 colour documents printed on card - more robust stand alone record.
‘Do not handwrite MAR charts or produce a MAR chart by attaching dispensing labels to a blank copy.’
Medication review
Rationaliation to avoid DNs administering wherever possible is so important (so having a pharmacist contact at the referral stage – to change the warfarin to DOACs or to refute the care workers can’t give CDs/eyedrops post op etc -
Pharmacy continuing to look at what gets administered is vital
Goal = single, electronic MAR chart for DN and Paid carers