Handling CDs

Following the aftermath of Xmas (and our recent SOP for dosette boxes) we have had a little bit of time to start some proactive work in the form of beginning to write our SOP on handling CDs which is now required from 1st January.

There doesn’t seem to be a huge amount of practical guidance around so we have used the information in the FAQs on the RPSGB controlled drugs website at http://www.rpsgb.org.uk/worldofpharmacy/
useofmedicines/controlleddrugs.html - very useful by the way) and the general SOPs guidance from the NPA as a starting point.

I’ll let you know how I get on!

More on dosettes

As I mentioned earlier this week, we have recently done a lot of work to really tighten up on our dosette box service. This work largely arose for three reasons:

• We didn’t have a formal written SOP for this service.

• The service, like so may others, had begun with a handful of patients and was now managing in excess of 100 and so needed more formal procedures in place to ensure that it continued to run safely and effectively.

• Because of the patient numbers involved one of the GP practices was not proactively telling the pharmacy about medication changes and so extra safeguards were needed.

So I started by talking to all the pharmacy staff involved in the service to check my understanding of the service (e.g. how were new patients initiated on the service and counselled by the pharmacy staff on the use of the weekly service; how did the pharmacy request weekly scripts; how were the dosette boxes assembled; how were changes in medication communicated to us, made by us, and communicated to the patient/carer).

And then I wrote a draft SOP which also acted to tighten up on a number of the pharmacy procedures, particularly:

• If a stock bottle was needed from an unchecked dosette box then a senior member of the dispensary team would verify and initial that the correct stock bottle had been removed.

• Keeping a formal written log of all changes to patients’ medication on the occasions where there wasn’t a script to back this up (e.g. GP surgery informing us of a medication which needed stopping).

• Using more experienced staff to run through the weekly scripts and pick up any medication changes that the surgery had not proactively told us about.

• Ensuring that patients using the service were aware of their responsibility for the dosette box and the cost of replacing any lost boxes (see Boxing shorts).

Once we had produced the draft SOP we shared it with the GP practices in order to get their input and let them see what service involved. This proved to be really helpful because the GP practices were becoming concerned about issuing weekly scripts and proactively letting us know about any medication changes.

However, once they had read the procedure they realised the work involved on a weekly basis by the pharmacy. In addition, they also agreed to slightly alter their procedure for issuing us with timely weekly scripts.

This now means that our procedure has been tightened up even further and that before an assembled dosette box is given to a patient, the second check that is performed by the pharmacist involves a double-check against the latest weekly script (hence picking up any recent medication changes straight away).

The service is still a very involved and time-consuming one but everyone is now much happier that we have a formal written procedure in place that has tightened up on a number of areas where errors could have occurred.

Boxing shorts

A couple of problems have arisen with our dosette box service this week.

The first was when a patient rang to complain that we had filled his box incorrectly since there were too many tablets in one of the compartments.

We asked him to bring the box back so that we could look at it since mistakes do happen (however, we do have a very robust dosette box procedure in place with the boxes getting checked twice by a pharmacist; once at assembly and once before they leave the premises).

When the box was returned the compartment that he was complaining about had been opened along with several others and so we had to explain that we couldn’t take responsibility for the contents of unsealed compartments. It later turned out that the carer had opened the compartments and some of the tablets had been moved.

The second problem was having to remind all patients using the service that they are responsible for the dosette box and that if it is misplaced they will be charged its replacement. This has never been a problem in the past but we have recently had a couple of instances where one patient will not take responsibility for a lost box, and in another case, a patient went into hospital with the box and the hospital kept it!

For new patients using the service we have always made them aware of this responsibility but we are now making sure that we enforce this message.

The game of the name

We’ve had a mixed bag of customers this week. I had one customer who came into the pharmacy to talk to me about his medicines after his friend had been ‘so complimentary’ about the advice I had given to her the previous day.

This did give me a bit of lift since it’s always nice to get positive feedback, and he actually wanted to talk through the fact that his GP wanted to switch his atorvastatin to simvastatin (which of course I know all about –see Switch Doctors).

We then had a lady in the pharmacy who was rather irate that we hadn’t supplied her with her usual brand of tamoxifen (she wanted a particular generic brand of the drug).

We tried to explain that we could never guarantee the make of generic that we received from the wholesaler each time, and that this would be the case in most pharmacies, but she was still unhappy and so took the script away to try another pharmacy.

More on technicians

I felt I must respond to a post on one of my earlier blogs about working with checking technicians (see Learning to use skills)

The post was from Martin who has a recently qualified technician and is uncomfortable about the role since he is still responsible for any errors that leave the store.

I can understand this since community pharmacists have long been used to working on their own in dispensaries and so being in full control of the dispensing procedure.

But I have to say that after working as part of a team of very capable dispensary staff and checking technicians, that I wouldn’t want it any other way. The liability issues are difficult ones but as long as there are robust SOPs in place then all staff should be clear on their roles and limits.

I would now feel quite uncomfortable managing the dispensing process on my own since I have actually found that several pairs of eyes are better than one when it comes to assessing the script, assembling it and then checking it.

I have now even got to the stage that if I do find myself in a position where I have solely dispensed the script, that I get another member of the dispensary staff to cast an eye over it since I have gotton so used to team working.

It’s also been fantastic over the busy Xmas period to have the dispensing of regular repeat medication carry on in the background while I was pulled all over the place.

Unhealthy inhaler

It's all back to normal this week (except for all the boxes of chocolate biscuits that are still left to eat).

It's been a little bit quieter this week and so we have started to catch up on all those jobs that just don'’t get done over Xmas.

One of them was to sort out all the patient-returned medicines since we had started to overflow with the amount that had been returned over the holiday period.

Before accepting any waste, the staff always check that there are no sharps in the bags, but what we didn'’t expect to find in one bag when we sorted through it was two packets of knitting needles and a box of teabags!

It'’s also that time of year for New Years resolutions and it did take me back a little when, after talking to a 14 year old boy and his concerned Dad about the overuse of the boy's blue inhaler and the fact that he now probably also needed a brown inhaler, I overhead their conversation when leaving the pharmacy which went along the lines of 'You really should also give up smoking son' - 'I know Dad, but it'’s really hard...'’

Worth shouting about

Here are some of the more interesting interventions that I have made lately (I realise that this has become a fairly regular slot in my blog but I’m passionate about shouting about all the really valuable clinical work that community pharmacists do every day):

• The lady given an acute prescription for a short course of itraconazole capsules who was adamant that she was going to insert them because the ‘doctor said that she was going to get something that she could insert’. I gently persuaded her otherwise.

• The wife administering her husband with Oxynorm Concentrate with the directions of ‘2mls to given when required for breakthrough pain’. She had misread the label and had been administering two full 5ml syringes each time.

• The patient newly prescribed a Symbicort inhaler who was going to stop using the blue reliever inhaler and carry on using the current preventer brown inhaler together with Symicort.

Happy new year!

Well here we are at the start of 2007, and as much as I love Xmas, it’s nice to get back to a normal working week and customers that aren’t panicking any more because we are closed more than usual. Had a couple of interesting encounters recently:

• With the family of a patient who had recently come out of hospital with quite a number of new medicines who were very confused about them all. One of the district nurses had originally rung us up to alert us of this and to ask if there was any way we could do a temporary dosette box.

We did agree but when the family brought in all the medicines a lot them were either CDs or prn medication which made a dosette box a waste of time (aren’t dosette boxes seen as the answer to everything!).

So we prepared a medicines reminder chart instead which described what each medicine was for and suggested timings of the prn medicines (since some labels just had ‘One when required’). The family were delighted.

• The daughter of a stroke patient who originally came in the query whether she could halve some of her mothers tablets since her mother was ‘having trouble swallowing them all’. On looking at her mother’s medication I could see that this wasn’t possible for the majority of them since they were controlled release preparations, and so I suggested altered timings for some of the medicines so that her mother didn’t have to take quite so many all at once.

However the key thing was to urge her to arrange a medicines review with the GP so that the GP could consider liquid preparations, etc. I explained that struggling to take a large number of medicines was a common problem in stroke patients and so she shouldn’t suffer in silence.