Dee Spencer

Thrush and worms

2008-04-23T09:56:00.001+01:00

Here’s a couple really good clinical interventions for you all:
• A script for Canestan Solution written ‘to be used TDS’ for a 8 day old baby. On taking this out to mum I checked how she was going to use it and she had been told it was for oral thrush! So I quickly rang the GP who said he was having a ‘really hectic day’ and got it changed to nystatin suspension. Mum was fine when I explained that one of the pharmacist’s roles is to act as a ‘double-check’ in the system as we dispense the scripts.
• A script for a 3 year old for mebendazole, with a dose that reflected a roundworm infection. So before I gave this out I asked mum if the family had recently been abroad to an exotic location (to which the answer was no) and to then describe the symptoms (which sounded like threadworms to me). So I rang the GP and with his, and the patient’s, agreement I scrapped the script altogether and treated the whole family on the Care of the Chemist scheme for threadworms.

Audit going well

2008-04-17T09:28:00.000+01:00

My multi-disciplinary methotrexate audit seems to be going down well. I’ve asked five patients so far; one refused point blank, two filled it in there and then whiles they were waiting for their scripts, and two took them away and have both returned them.

People seem happy to complete the questionnaire if I tell them that the point of it is to see how well they are being managed on their methotrexate and if there are any areas where the local ‘health authority’ can improve services.

So far, all the patients seem to be very well informed and very well looked after. One thing that doing this audit does, is make you really bone-up on all aspects of methotrexate treatment so that you can readily answer any questions (good for the CPD as well!).

Called to the bar

2008-04-09T16:45:00.001+01:00

We are now trying our very best to scan every bar coded script that comes into the pharmacy (especially since I read that 25% of scripts are now bar coded but only 1% of scripts are actually being dispensed in this way).

We now have two GP surgeries who are issuing bar coded scripts.

Information either seems to be getting a bit quicker at coming down from the spine, or we are getting more used to changing our way of working to accommodate these scripts (i.e. scanning them as soon as they come in, so that the information is ready for us when we do get to that script).

I still find that whoever is running the script through (including me!) isn’t looking at the patient’s record as much as they should to pick up new medicines, changes in doses, etc; but instead is concentrating on altering all the dose information on the script to patient-friendly terms on the label.

But we’ll get there I’m sure.

Methotrexate survey

2008-04-07T15:37:00.001+01:00

The PCT certainly seems to be busy at the moment. We have now just received the paperwork for our annual multi-disciplinary audit.

This one involves doing a small survey with all patients taking methotrexate tablets to see how much they understand about their therapy, how well they are being monitored, etc. The audit will run over two months.

In my opinion this is a great audit to do since we now have all the detailed information from the NPSA to give to patients about methotrexate therapy if they aren’t suitably informed.

Now that we have completed our annual patient survey, we will also have to start to think about our own internal annual audit.

Waste not

2008-04-03T12:41:00.000+01:00

The PCT have just starting running a medicines waste campaign. They have sent everyone bag inserts, posters, stickers, etc to try to better inform patients.

The GP surgeries are busy supplying this information with every repeat prescription that they issue so we have decided to put all our information away for the moment and to start using it once the GP surgeries stop.

We feel that this prolonged approach will have more of an impact if first the GP surgeries and then we give the patients the same messages about only ordering the medicines they need.

This approach also fits in better with what we are doing at the moment since from the last blog entry you will know that we are busy stuffing bags ourselves with the information about our new repeat prescription service.

Relocation (repeat after me)

2008-03-26T15:29:00.002Z

You may remember many moons ago that we developed a plan for boosting our business since it is likely that one of the pharmacies in the town is doing a ‘minor relocation’ into one of the local practices (the dispensing practice!).

Well we have now actioned our main goal which was to re-launch our repeat prescription and delivery service. This has taken some time and planning to e.g. produce all the advertising, bag stuffers, patient sign-up forms, etc; to write the SOPs and train the staff; and to get the GP practices on board with the new service (since the ‘new’ service primarily involves us requesting repeat scripts from the surgeries on patients’ behalves).

So we are currently busy signing up all our patients up for the service, and so far it is going very well (we started off just working with one surgery in order to iron out any problems). I feel that the timing of this launch is right since, of course, we have future-proofed our patient sign-up forms for EPS, etc and it gets patients used to requesting their repeat items from us in preparation for repeat dispensing (whenever that may be!).

Patient was three

2008-01-24T11:40:00.000Z

Here’s an example of why pharmacists provide a rather valuable service to the public!

Had a script in today for trimethoprim 200mg BD for 3/7’ to a patient with no date of birth on the script. The patient turned out to be a 3 year old and on checking the dose of trimethoprim it was the maximum daily dose for this age and I could have dispensed a syrup since no form was indicated on the script.

But it did immediately go through my mind that the doctor had just signed this script (the patient had picked it up from reception) without realising it was for a child. It was, of course, from the dispensing practice that we don’t have a great relationship with but this one had to be checked out.

Well it turned out that my gut feeling was right and so I modified the dose for the patient and got a new script issued from the surgery.

Survey completed

2008-01-22T11:38:00.000Z

We have finished collecting our patient surveys and they have been sent off for analysis. It’s taken us two weeks to get this completed.

We found that the majority of patients who were asked were more than happy to complete a survey while they waited for their scripts, etc. We didn’t once need to offer anyone an alternative way of filling in the survey (as you are supposed to do) by e.g. going online. So we will wait to see what our patients think of us!

EPS success!

2008-01-21T11:32:00.000Z

The PCT came to visit us today to check that we are using the first phase of the EPS system so we valiantly scanned a bar coded script for them. Luckily this one came down from the spine almost immediately (but I have to say that this is still very hit and miss). The owner of the pharmacy will now receive his EPS payment so he’s happy!

In the bag

2008-01-16T09:49:00.000Z

If you remember, I recently described the week of lost medicines. There was one case where we simply couldn’t resolve the issue with the patient. We had re-dispensed the item and made a note that in future we would always count the items into a bag in front of him.

I had my doubts whether that patient would return but he has on two occasions since and didn’t seem to mind the fact that we took him to one side and counted all his items into a bag.

Abusive language

2008-01-15T19:42:00.000Z

We’ve had to ban a second patient from using our pharmacy following abusive language in the shop.

It was a teenage boy and stemmed from the fact that I had refused to give him an emergency supply of his salbutamol inhaler following a recent emergency supply for the same thing.

You’ll know from my previous blogs that I’ve had to deal with refusing repeated requests for salbutamol MDIs before.

In this case, I had previously given him an emergency supply with all the appropriate counselling about using his preventers, getting his asthma reviewed, etc and I had made it very clear to him that I wouldn’t be prepared to do the same again.

So of course when he came in again for another emergency supply I got a load of verbal abuse and so we have written to him asking him not to use our services any more (this approach has so far worked from a previous incident).

Another world

2008-01-10T09:42:00.000Z

We have suddenly entered the world of EPS this week with a system upgrade and bar code scanners for the scripts.

One of our local surgeries is already using bar coded scripts so we now have lots to practice on.

I would echo what I have read in the pharmacy press that there still seems to be a lot of work to do with this system since it seems to be very hit and miss in terms of how long the scanned information takes to come down from the spine (from instantly, to 5-10 minutes, to never appearing at all!).

When it does work it is great to have all the information in front of you straight away without having to select all the individual drugs from the patients’ records.

But I wonder if it will make us less vigilant when scanning the whole of the patient’s record to look out for problems, and we inevitably have to go into each of the selected drugs to change the directions to something that makes sense for the patient.

Anyway, it’s a start!

The price of change

2008-01-08T09:46:00.000Z

Had a great patient return today of sixteen packs of unopened rosuvastatin tablets 10mg. Any one care to work the price out?

The PCT is busy swapping all patients on atorvastatin 10mg to simvastatin 40mg at another one of the local surgeries so we are busy fielding patient’s questions and making sure that they know about the grapefruit interaction with simvastatin.

Patient survey

2008-01-07T10:02:00.000Z

We started our patient survey today. As I said before, we are going with the NPA-recommended company that provides the paper based surveys since we felt this would better suite our patients.

I prepared a briefing sheet for the counter staff on how to sell the survey to patients waiting for NHS scripts and Care of the Chemist and off they went. We need to get 150 completed surveys off to the company to analyse so we will see how long it takes.

Missing item

2008-01-03T13:11:00.000Z

We have had a week of lost script items. We hardly ever get patients ringing up to say that we haven’t given them everything that was on their scripts, but over the holiday period we’ve had four!

Like everyone else we always count the items into a bag and then seal it before handing it out. If a patient then rings in to say that an item isn’t in their bag we explain our procedure to them and ask them to bring the entire bag contents back to the pharmacy so that we can check it over again (our worry always being that if we have counted the items into a bag and a patient is missing something then they may have something else that they shouldn’t have).

This usually means that the patients then go away and have a good look round again before coming back to the pharmacy – and this worked in three out of the four telephone calls this week when patients then rang back to say they had found their ‘lost’ items.

But we just couldn’t get to the bottom of it with our fourth patient and so after exploring all avenues we finally re-dispensed the item to them (what else can you do without making a big song and dance out of it?) with an explanation that strictly speaking we should be reporting the loss of the item to the police, etc.

We have also made a note in this patient’s record that in future we will count the items into the bag in front of them.

Keep on checking

2007-12-19T11:31:00.000Z

Made a good intervention yesterday. A lady had just been prescribed some sibutramine so out I went to tell her all about it.

On checking that she was going to go for regular BP checks she said the GP hadn’t mentioned anything like that. So I advised her to make an appointment with the practice nurse to start getting the necessary checks.

I also rang the practice to get this added to the patient’s notes to ensure that it will be done.

And then we dad one of ‘those’ scripts – you know, the out of town ones for a benzodiazepine where there looks to be an alteration on the script.

We didn’t have the item in stock and so sent the patient away which gave us the time to sort it out.

It was from our local CAHMS team and we got passed from pillar to post until we finally got to speak to the consultant who wrote the script.

‘Yes, I thought that might look a bit dodgy’ he admitted.

So at least we got it sorted out for the patient, but it would have made our life a lot easier if he’d altered it correctly in the first place.

A long wait...

2007-12-13T16:08:00.001Z

Hello again. I suppose it is rich irony that my last blog was titled "Urgent, but out of date..." and that was some considerable time ago. I'm sorry there has been a bit of a gap - and while on the subject of waiting, I’ve had a really busy day today. You know one of those days when you can hardly see the shop floor for people waiting for their scripts.

Just to top it all off nicely I had shouted a patient’s name and this lovely old man who was sitting down gave me a big smile and slowly got out of his chair. I stood patiently while he slowly walked over to me. ‘Mr Smith?’ I asked. ‘Oh no love’ he said, ‘I was stretching my legs while I’m waiting.'

Urgent but out of date

2007-09-24T12:10:00.000+01:00

Had a mum in first thing today who handed in a script for domperidone suspension from the local urgent care centre.

It wasn’t until we looked at it closely that we noticed it was out of date (you don’t often see this from ‘urgent care’ scripts).

Mum explained that her toddler had been sick during the night and so she had just dug this script out since she knew it was for nausea and vomiting.

I counselled her and off she went with the appropriate advice and some dioralyte under the Care at the Chemist scheme.

Inhaler checks

2007-09-20T10:46:00.000+01:00

Had an interesting one today with a girl asking for an emergency supply of her salbutamol inhaler.

Now we always check that patients are also using their preventer inhalers, and when they last had a supply of the salbutamol inhaler just to check for signs of overuse or over-reliance on the reliever.

When we checked this one, she had been dispensed two MDIs two days earlier. When I questioned her she told me she had lost them, so what do you do, particularly when you know her asthmatic boyfriend was refused a similar supply the day before because of a definite over-reliance on his reliever?

Well I told her that I would make the supply this time in good faith but that in future she would need to sort this out with the practice.

I also made a call to the practice’s asthma nurse to let her know what was going on and hopefully they will be called in for a review.

Ironic

2007-09-17T11:35:00.000+01:00

I had a great week last week for querying and stopping potential overdoses of drugs, and they all seemed to come together in the space of two days. Here are some of them:

* The patient taking perindopril 8mg and 2mg tablets. On querying this, the 2mg tablet was stopped.

* Tramadol MR 200mg being prescribed QDS. Got this one changed to the BD dosage.

* Co-danthrusate being prescribed on repeat at a dose of 2 TDS. This should have just been docusate at this dosage.

I found making all these important interventions quite ironic so soon after the MHRA decided to allow us to continue to sell pseudoephedrine!

Switch info

2007-09-13T10:47:00.000+01:00

The PCT pharmacists have been in again today to let us know about three switches they are planning to do at one of the local practices.

They are atorvastatin to simvastatin, risedronate to alendronate, and gaviscon advance to peptac.

They are asking the practice to send out letters to patients about the switches, and we have already started to adjust our stocks.

What we then thought about was the issue of not consuming grapefruit when dosette box patients are swapped from atorvastatin to simvastatin because you can't get that amount of detailed information on the back of the dosette boxes.

So we have written our own letter for these patients to tell them about not consuming grapefruit when they are swapped to simvastatin.

Hydrocortisone problem

2007-09-06T13:18:00.000+01:00

Had one of those annoying situations today where a lady came in asking for hydrocortisone cream 1% to buy for use on her face.

She understandably got rather frustrated with me when I told her that I couldn’t sell it for use on the face since this wasn’t covered by the OTC license.

I remember getting this situation a lot 10 years ago when OTC hydrocortisone was fairly new to the market and I’m surprised that this is still happening.

Recruiting

2007-08-31T13:54:00.000+01:00

I’ve been really busy today, along with the dispensary manager interviewing for three new members of dispensary staff.

The positions are to cover maternity leave, replace the dispensary assistant who prepares our dosette boxes and who has just announced she’s leaving (big blow this one!), and a new member of staff to really develop our collection and delivery service and ultimately repeat dispensing.

We just advertised the positions in the shop since the owner strongly feels that he wants to continue employing local people. We had 12 applicants and selected 6 for interview based on the CVs.

I devised a standard set of questions for each candidate and I think we have agreed on the 3 that we will offer the positions too. So fingers crossed and I will keep you posted.

Stand and deliver

2007-08-30T14:14:00.000+01:00

A couple of weeks ago someone asked a question about our collection and delivery service and how we prevent possible abuse of the delivery service. My answer is below and I’m also posting it here since you may find it useful or have further comments to add:

In terms of policing our delivery service, we seem to do three things in the pharmacy which makes it run fairly smoothly. We:

* Charge a nominal charge if a patient requires more than one delivery a week.

* We don’t guarantee a delivery time and just say between ‘4-6pm’ for example. This isn’t a problem for the truly housebound patients, but we find that the more mobile patients prefer to collect their prescriptions rather than wait round for a delivery (since we won’t push it through the letter box or deliver it to a neighbour!!).

* If we think someone is trying it on then we will ask them again if there is no way that the script can be collected since their delivery will take up a slot that may be needed by a vulnerable housebound person.

We have always openly advertised this service and deliver between 9-11am and 4-6pm so it does take up quite a bit of staff time.

Well done LPC!

2007-08-23T12:18:00.000+01:00

Well today we finally received the agreed PCT-wide SLA for supervised methadone and buprenorphine. Well done to the LPC for pushing this one through.

Haven’t had a chance to read it in any great detail yet, but we can’t start providing the service until we receive the necessary accreditation by doing the relevant CPPE distance learning pack.

So I’m off to order my copy tonight.

To show we care

2007-08-22T09:40:00.000+01:00

I’m still really enjoying using the Care at the Chemist scheme. Earlier this week I supplied a non-sedating antihistamine to a 10 year old boy who had been given a repeat prescription for his ‘usual hayfever tablets’ of chlorphenamine.

Now I really didn’t see the point of making a 10 year old child drowsy at school, so I discussed this with mum and supplied an alternative on the Care at the Chemist scheme.

She came back in today to say that this has been a great success and that she would continue to use the scheme in the future.

Further interventions

2007-08-10T11:19:00.000+01:00

Here’s a couple of good clinical interventions that I have made this week:

• The lady who had just been issued with a new Serevent inhaler and was going to stop using the brown one and the blue one, and only use the Serevent as a prn reliever. So I explained that she must continue to use the brown one regularly, start to use the Serevent regularly, and carry on using the blue reliever prn.

• The man who was allergic to penicillin and had been prescribed a 2 week course of erythromycin along with his regular felodipine mr 10mg. On ringing his GP I suggested that he write me another script for a 2 week supply of felodipine mr 5mg since it seemed sensible to halve the dose of this drug while taking the erythromycin. ‘Now that’s a good idea’, said the GP and off I went to sort it out.

Within reason

2007-08-07T12:49:00.001+01:00

Remember I told you last week (see Beyond reason) that I had one of those really frustrating situations with a couple who were convinced we had wrongly dispensed some Calcichew D3 Forte to them?

Well they came in today and asked to see me, so out I went with my ‘boxing gloves’ at the ready only to be met by a very apologetic pair who said they had gone home and had found the correct tub of calcichew that we had recently dispensed for them.

They then quietly asked if they could continue to get their prescriptions dispensed at the pharmacy since they said they had been ‘out of order the last time we spoke’.

I said that of course they could and thanked them for their apology. It made me feel good about the world today.

One hundred a week

2007-08-02T14:28:00.000+01:00

Today I dispensed a prescription for 100 co-codamol 30/500 to a lady who has been getting increasing amounts on prescription.

When I checked her records I could see that she had recently started to get 100 tablets a week which is way over the recommended limit of 8 tablets a day. When I queried this with her she happily told me that she was only taking 8 a day, and that her dad was also taking them.

So later I rang her GP to check he knew what was going on since this surgery has a really good ‘over-use’ alert on their system and I was surprised that it hadn’t been picked up at their end.

I told the GP what the patient had said and pointed out how often these scripts were being issued. When he checked he said that they hadn’t picked up on this due to the way in which the drug had been entered onto the system. He was very grateful for the call.

Good service

2007-07-30T10:16:00.000+01:00

The EHC service is going really well. In the first couple of weeks we must be averaging about one consultation per day, which isn’t bad for a newly launched service.

The practice manager at the local GP surgery rang today asking me to supply them with information about the service for the reception staff to hand over.

I would imagine that our consultation rate will start to increase nicely.

Beyond reason

2007-07-26T14:34:00.000+01:00

Had one of those really frustrating encounters today when a patient is convinced they are right and I am wrong, and no amount of reason can persuade them otherwise.

It was an elderly couple who came in to see me with a pot of calcichew D3 forte with our label on it dated August 2006. The bottle was full of brown tablets, which definitely weren’t calcichew D3 forte.

They were convinced that this was the bottle we had dispensed to them that week and that we had made a mistake.

I tried to point out that this bottle had been dispensed to them nearly a year earlier and that they must have used the empty bottle to start storing these unknown tablets, but they wouldn’t have it since they had ‘no other bottles in the house’.

So I gave them an emergency supply of the tablets, asked them to please throw away the unknown ones, and told them that they would have to arrange a further prescription from the GP surgery.

Fevered activity

2007-07-24T17:03:00.000+01:00

We received a PCT circular today asking us to take account of the recent NICE guidance on treating fever in children.

I’ve made sure that all thestaff are aware of the guidance regarding antipyretic medication and that we are all ‘singing from the same hymn sheet’ regardless of whether we are supplying medication on prescription, on Care at the Chemist, or over the counter.

It did turn out to be quite a useful exercise since there were discrepancies among the staff as to how they were advising parents to use paracetamol and ibuprofen.

However, it did make me smile slightly because I see all sorts of weird and wonderful doses coming through on prescriptions for antipyretics which I inevitably have to alter (after talking to the parents of course).

Double dosette

2007-07-23T14:35:00.000+01:00

We had a second instance today where we have recently set up a dosette box for a patient only to be told a few weeks later that the patient doesn’t like using the box and can we please stop supplying it.

Now that’s no problem, but what doesn’t seem to be appreciated is the time we take to set the service up, organise things with the patients/carers, etc - let alone the time it then takes to dismantle the unwanted trays of medication that are left with us.

So, I am just going to monitor this situation for now. If it starts to happen more frequently then we will need to seriously consider setting up our own screening tool to check the suitability of patients for this service.

I’m not convinced that other local healthcare professionals are applying any sort of criteria before they ask us to set up the service.

Testing time

2007-07-16T10:06:00.000+01:00

An elderly lady called today asking me what she could do about her fingers since they were getting really sore from finger prick testing.

On looking at her records I could see that she had Type 2 diabetes but wasn’t using insulin, so I asked her how often she was testing her blood glucose levels, to which she replied twice a day.

Not wishing to tread on any one’s toes at this point I said that I would discuss this with her practice nurse and get the nurse to give her a ring (since the local guidelines quite rightly recommend testing twice a week).

I explained this to the nurse and she told me that the lady was really well controlled with a recent HbA1c level of 7. Therefore the nurse agreed to ring her back to ask her reduce her frequency of testing.

Practice leaflet

2007-07-09T14:30:00.000+01:00

We’ve had the first draft of our practice leaflet back from the NPA and it looks really good. We are now turning our attention to pushing our collection and delivery service again.

We have revamped our PIL and are going to try to get it to look the same as the practice leaflet. In the meantime, I’m trying to find the time to start our annual patient survey.

Methotrexate interventions

2007-07-05T16:08:00.000+01:00

Made a couple of good interventions this week with methotrexate, and on both occasions I gave the patients copies of the recently published NPSA methotrexate PIL which is excellent in my opinion.

* The first patient had just been initiated on methotrexate from the hospital and had brought in his FP10(HP) to be dispensed. So I spent some time with him going through the NPSA PIL and making sure he already had his monitoring book, etc. He was really pleased when he left.

* The second patient had been prescribed a course of penicillin for a skin infection. Patients on methotrexate should usually be prescribed erythromycin for skin infections but that had been tried and had failed. But I contacted the GP anyway and we agreed to ask the patient to reduce his methotrexate dose for the next two weeks in order to try to avoid any toxicity.

I also gave him the NPSA PIL so that he could clearly see which side effects to look out for. Again, he was really pleased with the service.

EHC PDG OK

2007-07-02T15:00:00.000+01:00

We launched our EHC PGD enhanced service this week. We have initially informed all the local GP practices and put posters up in the pharmacy (which I had to do myself since there is no advertising material available with the scheme!).

I also did my first consultation today which went well. I’ve decided to just talk to the patient first and then fill out all the paperwork with her second.

The paperwork is pretty cumbersome and I would spend more time looking at that than concentrating on talking to the patient, if I tried to do both at the same time.

Special order problem

2007-06-28T15:55:00.000+01:00

I spent some time today making sure that a mum got hold of some heart medicines for her four year old daughter.

This morning she brought in a prescription for this drug and told me that she had completely run out and needed to get hold of further supplies today in order to give her daughter the required evening dose.

What hadn’t been explained to her was that her daughter’s medication was a ‘special order’ that wouldn’t be with us for at least 3-5 working days.

I rang the hospital pharmacy department (which was 25 miles away) to ask for their advice and they told me it was possible for the patient to obtain further supplies today if she contacted her consultant who could then instruct the pharmacy department to supply it.

The trouble was that the patient didn’t have any transport which I informed the hospital of, but they said that one way or the other they wouldn’t leave the patient with no medication.

So I let mum know and she went home to sort it out.

I rang her this afternoon to check everything had worked out OK and she told me that the hospital had arranged for a supply to be made that evening from a local hospital which was only 5 miles away.

It was great that everyone pulled together to ensure that this lady received the necessary medication on time, but none of this would have happened if she had been told how long it would take to obtain supplies of this medication in the community.

Loose ends tied

2007-06-25T10:02:00.000+01:00

In our continuing efforts to tie up all the loose ends in terms of complying with everything in the pharmacy contract, I had a look at the NPA template patient information leaflet that is now available and put my order in.

It’s great to have this sort of support available (for a small fee of course)!

An extra dosette of fun

2007-06-21T12:10:00.000+01:00

We’ve had great fun and games with our dosette box service this week.

First of all, a nursing home insisted that we hadn’t supplied the extra prn medication with two of their resident’s dosette boxes.

We are always very careful to ensure that these ‘extras’ are secured to the boxes and so asked the home to have a good look round.

Thankfully they did ring us back to say that they had found the ‘extras’ tucked away in the respective residents’ rooms.

We also have a growing issue around a lack of communication and understanding of the dosette box service when patients are discharged from hospital.

The bottom line is that we can’t make any changes to the dosette box without instructions from the GP practice. However on two occasions this week we’ve had patients’ relatives come into the pharmacy to say that the hospital had stopped some of the drugs and so could we remove them from the dosette box?

This then involved us following up on the discharge medication sheet and then ringing the GP practice to get the go-ahead.

We have also had one occasion this week where the hospital has contacted us directly and asked for medication in the dosette box to be changed.

Again we explained that we are unable to do anything without the say-so of the GP practice (much to the surprise of the hospital!) and so asked the hospital to fax us the relevant discharge information so that we could then contact the GP practice and the patient to take this forward.

As we all know this type of service takes up a great deal of our time and we simply couldn’t do it without the ever-contentious issue of weekly scripts.

Keep taking the medicine!

2007-06-18T15:19:00.000+01:00

Had an interesting telephone conversation today with a lady who hadn’t been taking any of her angina medicines for the past month because she had been ‘too busy’ to re-order them on repeat.

She had started to get headaches and so went to get her BP checked by the practice nurse. Needless to say her BP was very high, but she hadn’t told the nurse that she had stopped her medicines and had just gone home and re-started them all.

She felt so ill after doing this that she had stopped them all again and rang me for advice.

I explained to her that because she had completely stopped them all for some time, that she would need to slowly titrate most of the doses back up again.

I also persuaded her to tell her doctor since he was the only one who could monitor her and advise her on how to correctly re-start all her medicines.

EHC PGD accreditation

2007-06-14T15:41:00.000+01:00

I received my accreditation certificate from the EHC PGD evening today and so we are now busy setting up the service.

We’ve got a lockable cupboard in the consultation room for all the paperwork and the PILs, and we are busy making sure that we have all the contacts for social services (for the under 14s) and for signposting the service when we can’t provide it.

We are going to begin to advertise the service just to the local GP practices and depending on uptake, we will take it from there.

Badge of honour

2007-06-11T09:54:00.000+01:00

Finally feel like I’m making a bit of progress with the NPA Interact training for the new staff. One of the staff members has recently qualified and wears her badge very proudly, and the other staff member is now half way through.

Once I have got this second staff member through her training I’m going to start doing some revision sessions with the more experienced staff members. All good fun!

Touching on surveys

2007-06-07T10:46:00.000+01:00

Today we started to look at how we are going to run our patient survey (probably over the summer).

We will be using one of the NPA-endorsed companies to help us carry out the survey and we’ve been discussing whether we should go for the touch screen survey or the paper-based survey.

We decided that we will use the paper-based package since it will suit our patient population much better.

The main thing against the touch screen survey for us is that we can envisage all the children playing with it; and we feel that our high elderly population will be more comfortable with paper and pen rather than with a touch screen.

I also personally feel that the paper-based survey will encourage more useful patient feedback from the open question at the end of the survey (i.e. ‘Do you have any other comments?’).

Latest interventions

2007-06-06T14:28:00.000+01:00

Here are a few of interventions I have made this week:

1. Checking with a GP that a dose increase of modified release ISMN should be taken as two in the morning rather than as one twice a day (which would mean a loss of the nitrate-free period).

2. Getting a low dose of newly-initiated acamprosate changed to the correct dose.

3. Getting EHC removed from the regular repeat medication of a 17 year old girl.

4. Counselling a mum all about a new prescription for Desmotabs for her son. She had received very little information about why her son should be taking them and the importance of fluid restriction, etc.

Tracking the counterfeits

2007-06-04T12:21:00.000+01:00

Had a very busy week last week catching up after the bank holiday and dealing with the patient recalls on the parallel imported counterfeit medicines.

The local GP surgeries gave us excellent support by quickly ringing all the patients who could have been supplied with these medicines (we did have telephone numbers for some of the patients affected).

We also had to think about how to explain this to patients and decided on the terminology ‘faulty batches’ rather than ‘counterfeit medicines’.

One patient had actually been supplied with one of the batches of olanzapine that was being recalled.

We are now left with one patient who we can’t get hold of. The surgery has rung him, we have knocked on his door during our deliveries, and we have also sent him a letter in case he is currently away on holiday.

Mr Angry

2007-05-29T10:17:00.000+01:00

Had a difficult consultation with a gentleman today who was travelling abroad and needed malaria prophylaxis. On consulting the NPA charts it was clear that he needed one of the POM malaria regimes.

However, he was insistent that for various reasons he couldn’t take any of these and ‘just wanted to buy’ some chloroquine and paludrine.

So, rather than refuse him the sale outright, I took his telephone number and said I would look into it further.

I rang one of the national help lines to enquire about the efficacy of chloroquine and paludrine and was told they were a complete waste of time.

I then rang the travel nurse at the patient’s practice and she informed me that she had also been trying to persuade him to take one of the POM regimes and that he was coming back to see her to get his jabs.

I rang the gentleman back and told him my reasons for refusing the sale (i.e. that it wouldn’t be in his best interests if I did, and that I wasn’t willing to take the clinical responsibility for selling him something that wouldn’t work).

He was furious and didn’t see why I just couldn’t ‘sell him the tablets and be done with it’. I haven’t heard anything since but I really hope that the travel nurse could finally make him see sense.

Pseudoephedrine points

2007-05-24T15:30:00.000+01:00

I had another word with the counter staff today to stress how important it has become to closely question and monitor sales of pseudoephedrine-containing products.

I was prompted to do this following the publication of the MHRA ‘test’ of pharmacy in Cleveland to determine how easy it was to purchase multiple packs of products containing pseudoephedrine.

I wholeheartedly agree with the swell of pharmacy opinion that it would be a huge backward step for pharmacy if the drug were reclassified, but I was also really disappointed at the Cleveland results.

Elderly organs

2007-05-23T15:41:00.000+01:00

A lovely elderly lady came into the pharmacy today asking if we had any donor cards. As I handed one over she proudly said: “I’ve still got all my organs dear so I thought it was about time that I got myself one of these.” I couldn’t help but smile…

It's what pharmacy is all about

2007-05-21T14:24:00.000+01:00

We are really beginning to get full use out of our consultation room now and patients also seem to be getting more used to the idea.

During the past week for example, I was able to use the consultation room to check that a little boy did indeed have chicken pox before I provided him with paracetamol and chlorphenamine under the minor ailments scheme; I could have a private discussion with a child carer who was embarrassed to discuss her problem (which turned out to be threadworms); and the counter staff used the room frequently to check for head lice before providing the necessary treatment under the minor ailments scheme.

For me, this is what pharmacy is all about. It’s giving me a great deal of job satisfaction to be able to work in this way.

Screening near you

2007-05-18T16:26:00.000+01:00

Staying with the sexual health theme, we received the latest figures from the regional Chlamydia screening programme today.

The stats show who provided Chlamydia testing kits, broken down into locality and service provider.

In every locality the highest number of testing kits were given out not by healthcare providers but by colleges, universities, prisons and army barracks.

However it’s great to see that community pharmacy is playing an active role in this service, particularly with public health so high on the government’s agenda.

Training points

2007-05-14T14:57:00.000+01:00

When I started at the pharmacy last year I put my name down for training in order to become accredited to provide EHC free of charge under PGD to the over 14 year olds. At the last minute this training event was cancelled (see That'll teach me) and so we haven’t yet been able to provide the service.

This week, the re-arranged training evening finally arrived and so off I went. It was a really informative evening with an exam at the end. It was also attended by a real mix of pharmacists, from pharmacy managers of independents to new locums in the area who wanted to make themselves more employable by getting this accreditation.

There was also a locum from a multiple 100 hour pharmacy that is required to start providing the service under the terms of the 100 hour contract. This pharmacy is an interesting one since only one of a number of locums showed up for the training, and as part of this service the pharmacy has to ensure continuity of service as far as possible and signpost when the service can’t be provided.

Providing continuity of service is the main reason we haven’t yet started (i.e. until all our pharmacists are accredited) so it will be interesting to see what the 100 hour store now decides to do.

How to inhale!

2007-05-03T16:51:00.000+01:00

Had a lovely old gentleman in today who had been using various MDIs for his COPD. He had been given a Volumatic to improve his technique so I took him into the counselling room to show him how to use it.

However he understandably wasn’t too happy about carrying this around so I showed him how he should be using a MDI on its own (with my placebo inhalers that I had great fun getting hold of last year!).

He actually had a good technique apart from the ‘inhaling in’ bit which I couldn’t quite get him to understand until he brightened up and said: ‘Oh, you mean inhale like you are sucking on a fag.’

Well after that he was perfect, however the irony wasn’t lost on me…

Running out of time

2007-05-02T12:16:00.000+01:00

I told you last week how I’m beginning to feel like I’m drowning in work. Well this morning I received a letter from the NPA training department to say that the time on our Interact training for two of our staff is running out.

The reason for the delay in training has mainly centred around one pharmacist leaving and a delay until another pharmacist (i.e. me) was recruited.

I also don’t believe in just asking the staff to complete the Interact sections on their own. I spend time with them going through all the sections, checking they are happy with product choices, and particularly pretending to be a customer with various ailments in order to check their understanding - but of course this all takes time.

So I’ve got an extension on the time for both of them to complete the course and we’ll all just have to get our fingers out to make sure they are given the dedicated training time to complete their courses on time.

That sinking feeling

2007-04-26T16:59:00.000+01:00

Today, I picked up on a prescription where I had made a mistake.

I hate that sinking feeling that you get when a patient rings up to query a medicine they have been given. This involved a lady who had been started on the brand Dilzem in hospital and had continued to be prescribed it on FP10.

The trouble was that the script was written generically with Dilzem in brackets at the end and I had the brand Adizem picked for me. I had obviously seen generic diltiazem on the script, missed the ‘Dilzem’ at the end, seen that Adizem had been picked and assumed that this was the brand that the patient had (I believe this is called ‘root cause analysis’!).

So when the lady rang to query the brand we realised the mistake, swapped it over and apologised to her.

At least this mistake will cause no harm to the patient but we have now tightened up on our dispensing procedure (especially me!) to make sure we triple check scripts for generic diltiazem modified release preparations.

I'm not waving

2007-04-25T12:21:00.000+01:00

I’m starting to feel like I’m drowning this week. Like everyone else we’ve had a really busy Easter and so all the proactive work has been put on hold.

The trouble is that it all seems to keep piling up. I’ve made a start on our SOP for CDs but haven’t got very far, and all our action points from the RPSGB Inspectors visit aren’t yet complete.

On top of this we’ve got all the work to start on improving our business with all the multiple changeovers in the area (following a very quick refit we now have a Boots Local near us!), MURs to begin once we get the new form, and of course we now have the patient survey to think about before March next year.

I certainly won’t get bored over the summer.

Special information

2007-04-23T10:05:00.000+01:00

One of our regular customers came in this morning to ask for some further information on a GTN ointment that had been specially made up by the hospital.

Because it was a ‘special’ she didn’t receive a PIL with it and wanted more information about the product. So I talked to her about it and gave her a PIL from an equivalent preparation which she was very pleased with.

It has never occurred to me before that when we supply these ‘special’ extemp preparations that there isn’t a PIL to go with them. Has anyone got round this problem?

Frustrating time

2007-04-19T14:11:00.000+01:00

I’ve had a really frustrating time this week trying to get hold of some sheaths for a gentleman who was rapidly running out of them. We phoned our wholesaler to order it as a special line and were promised delivery in 2-3 days.

We checked this delivery date again 2 days later and were assured that they would arrive the next day. The ‘next day’ came and went, and on calling the wholesalers we were suddenly told that it now be a further 5-6 days!!

Now with only 3 days supply of his sheaths left, we rang the manufacturer, placed a direct order and were promised next day delivery (for a price). Again the ‘next day’ came and went and on calling the manufacturer we were told that our order hadn’t been put through as an overnight delivery, but it would be right away.

On ringing them the next day we were told the old old story that the courier ‘couldn’t find us’ and they would rearrange for delivery.

Well, by this time the poor man had run out completely and so we gave him a few more days supply of a sheath we already had in stock until his sheaths finally did arrive. It was so frustrating and time-consuming to have been messed around by both the wholesaler and the manufacturer.

Tramadol substitute

2007-04-12T12:19:00.000+01:00

Had a phone call from a worried daughter this morning. Her father had been prescribed tramadol by the hospital but it was making him feel very sick. He was already taking paracetamol but that was only ‘taking the edge off the pain’.

She had rung the hospital and was told by one of the nurses that the community pharmacist could provide an equivalent painkiller.

I explained that of the painkillers available OTC, nothing was strong enough to match tramadol and that of the paracetamol and codeine combinations available to buy, the dose of codeine in these preparations was so small that it added no real benefit over paracetamol alone.

So I advised her to speak to her father’s GP and later that evening she came with a script for co-codamol 8:500 which, of course, I could have supplied myself! I don’t yet know if they did any good or not.

Fully prepared

2007-04-10T14:09:00.000+01:00

This afternoon I handed out a course of metronidazole to a gentleman with my usual counselling of no alcohol, etc.

“Oh, don’t worry,” he said, “I’ve just finished a course of these and so I know all about avoiding alcohol. I had a skin full last night to keep me going until I finish this lot.” Nothing I could say to that really…

Great opportunity!

2007-04-05T15:10:00.000+01:00

This morning I had yet another call from a pharmacy recruitment agency asking for me by name, and letting me know that there were now ‘great opportunities’ for me locally if I wanted to move from my current position (bit of a coincidence with the new multiple moving into town don’t you think?). So again I politely told them that I was very happy where I was.

Competitive edge

2007-04-04T13:30:00.000+01:00

Recently I told you that there has been a change of ownership of a pharmacy in the town which has proved to be particularly advantageous for us in terms of swelling of new patient numbers.

The owner of the pharmacy where I work is naturally keen to encourage these patients to continue to use our service, but he is also aware that the new multiple is likely to be pretty aggressive in building its business back up so we have given a lot of thought to how we can really start to improve the business in order to combat this.

We have come up with a number of key strategies to do this which we aim to take forward over the coming months.

These include really pushing our collection service again; further developing the dosette box service and other services to support people who are struggling with their medicines; being 100% ready when the local GPs finally decide to implement repeat dispensing; starting to do MURs as soon as the new form is released; and improving the ongoing training of the counter staff. I’ll keep you informed of progress.

Simvastatin and antibiotics

2007-04-02T09:50:00.000+01:00

An elderly lady rang me today to double-check that she had done the right thing by stopping her simvastatin whilst taking a course of cefalexin.

Her logic was that she had been told in the past to stop her simvastatin whilst on a ‘different antibiotic’ (i.e. erythromycin) and has assumed that this applied to all antibiotics.

I told her that it didn’t apply to all antibiotics, to re-start her simvastatin, and that I would always tell her if she needed to stop her cholesterol drug if she got a future course of antibiotics that did interact.

It just got me thinking if there are other patients out there with the same assumptions. I always counsel patients about taking simvastatin and erythromycin together, but I’ve never stressed to these patients that they should continue taking simvastatin when they are prescribed further courses of antibiotics that don’t interact.

Has anyone else come across this?

More encounters

2007-03-29T13:04:00.000+01:00

Had a couple of interesting patient encounters this week:

• The gentleman who had been prescribed an acute course of diclofenac. While I was counselling him about how to take it and the possible side effects, he told me that he had had a stomach ulcer in the past.

I advised him to speak to the doctor again which he did there and then. He asked us to shred the prescription since the doctor had advised an alternative painkiller which he already had at home.

• The lady who came in with a script for a single 30g tube of permethrin cream for scabies. We always supply the PRODIGY PILs with conditions such as this (e.g. scabies, threadworms, headlice, etc) since they describe all the other important measures, apart from the drug treatment, that patients need to follow and patients often find it embarrassing to talk about these conditions (even in the private consultation area).

On running through the information in the leaflet the lady could see that she needed a second tube of cream for the second treatment 7 days later, plus treatments for the other members of her family so she went back to the surgery and came back with the relevant scripts.

Adverse reaction - from doctor!

2007-03-27T09:32:00.000+01:00

I had an interesting discussion with one of our local GPs this week. We get scripts mainly from three GP practices, two of which we have a great relationship with and one (a dispensing practice) which we don’t.

The upshot of this is that if there is a problem with a script, we can readily sort it out for patients from the two non-dispensing practices, but if it’s a script from the dispensing practice we send the patient back (it’s just over the road) since this has proved in the past to be more effective than the pharmacists trying to ring to speak to the doctors.

Now I don’t like working this way since it’s not in the patient’s best interests, so when I got a script for a steroid nasal spray for a 4 year old which, on talking to the mother, I knew should have been a steroid inhaler I decided to ring the practice myself.

The doctor concerned had meant to prescribe an inhaler but was so unpleasant on the phone that I won’t be in a hurry to try that again.

I think it’s such a shame when all health care professionals can’t work well together to ultimately provide patients with a safe, quick and effective service.

Taking the plunge

2007-03-26T11:40:00.000+01:00

I recently described a bag of patient-returned medicines which also contained some knitting needles and tea bags. Well we can now better this after having another bag of medicines returned to us which also contained a toilet plunger!

We do explain to patients that we will open the bag and sort through the medicines that have been returned to us, but it doesn’t seem to stop some rather curious items appearing from time-to-time…

Here are some of the recent interventions I have made:

• Telling numerous patients prescribed a short course of erythromycin to stop taking their simvastatin whilst taking the antibiotic.

• Getting a short course of trimethoprim changed to an alternative for a patient also taking methotrexate.

• Getting an ACE inhibitor removed from a repeat prescription which also contained a newly prescribed angiotensin II inhibitor.

Multiple advantages

2007-03-20T15:07:00.000Z

One of the multiple pharmacies in the town has recently been bought out by another multiple and the change-over happened this week.

It has proved to very advantageous for us since we have started to see a significant number of new patients that have been unsettled by this change in ownership. This was particularly the case when the multiple closed down over a weekend to allow for the change-over to take place.

I hope that we can impress these new patients enough to encourage them to continue to use our pharmacy.

Very interesting!

2007-03-13T09:49:00.000Z

We’ve had some interesting H. pylori eradication regimes prescribed recently. A one week course of a PPI, amoxicillin and clarithromycin is usually prescribed in our area and we have had a number of variations to the licensed combinations, for example:

• The correct dose of amoxicillin but not enough to last for a week.

• Too small a dose of PPI and the incorrect dosage of amoxicillin over a week.

• One lady who had had a flare up of a previous ulcer, had been for a blood test and then had been given a script for eradication therapy with no explanation as to why she was taking it. The dose of PPI was in excess of the licensed combination and the dose of amoxicillin was incorrect.

One of those days!

2007-03-12T09:38:00.000Z

We've just had ‘one of those days’. We had a number of dispensary staff off sick and on holiday and so over lunch there were periods of time where there was only one pharmacist and one technician in the dispensary (very short staffed for us).

And of course it became extremely busy with prescriptions. Most of the patients who were waiting were regulars who are used to a prompt service so it didn’t help when they all started cheering every time we handed out a script!

Finding an answer

2007-03-08T09:29:00.000Z

I’ve had quite a few interesting patient enquiries this week for which I’ve needed to contact the relevant pharmaceutical companies. Some of them are:

• Can you mix Movical sachets in warm water? Answer: The company is aware that this has been done but doesn’t have any stability data and so doesn’t recommend it.

• There is grapefruit flavouring in Idrolax sachets so will this interact with simvastatin? Answer: No.

• Can a person who has had a cataract operation two months previously start to use Opticrom eye drops again for an allergy? Answer: Yes.

• Can a patient with chromic urticaria increase the maximum licensed daily dose of 180mg Fexofenadine (on the advice of their GP)? Answer: The company has studies to show that doses far in excess of 180mg daily can be administered safely but a consistent clinical benefit has not been shown.

First, find some food

2007-03-05T10:04:00.000Z

I felt sorry for an elderly lady yesterday. It was about 10am and I gave her some doxycycline which stated that the starting dose of two capsules should be taken that morning.

However, when I advised her that she should take this dose after food she said ‘Oh well, I’ll have to wait until I get home to take them because I’m off to visit my daughter-in-law now and she never feeds me.’

Never assume

2007-02-23T11:21:00.000Z

Here’s a couple of interventions that I have made recently, just proving the point that even on repeat prescriptions you can never assume that the patient is taking them correctly.

The patient who had a dose increase on fluoxetine. To make sure, I checked that she knew to take it in the morning (since the script was labelled one daily). ‘Well I do now’ she said. ‘No-one told me when I first starting taking it, so I took it at night and didn’t sleep for a week!’

The parents of a baby girl who had recently been started on a small prophylactic dose of cefalexin suspension. On giving the bottle out, I asked if they knew that it expired in 14 days and to throw the remainder away and get a fresh supply. Yes they replied, they had eventually worked that out for themselves but thanked me very much for pointing it out straightaway.

Too minimalist

2007-02-22T09:49:00.000Z

We’ve just had our usual monthly batch of returned scripts from the PPD. We do try our best to remember to add manufacturer details/prices to the more obscure scripts, but it’s so annoying when we get scripts returned for really common drugs when there is just one brand, or for the creams/lotions that have been prescribed generically and the computer system hasn’t endorsed the brand.

Apparently the computer software that we use has two endorsement settings – one which lists absolutely every detail, and one which lists the bare minimum.

We were actually asked to switch the program to the minimum endorsement setting but now it appears rather too minimum and if we keep getting these types of returned scripts back (yes I know about the rules that the PPD has to follow) then we’ll have to switch the endorsement program back again.

That age old problem

2007-02-19T12:23:00.000Z

I made some real clangers last week by incorrectly guessing at people’s ages.

You know how it goes when you give a script out and you want to pass on some information but the person who collects it isn’t the patient. I usually ask if it’s for a relative, but on a couple of occasions I have assumed people’s ages and got it badly wrong.

The first script was for a 65 year old women – the lady who stood up to collect it looked around that age to me so I took her to the counselling area and started to explain a few things until she said, ‘But this is for my mother!’.

The second script was for a 55 year old women - and a gentleman stood up to collect it. Instead of saying my usual ‘Is this for a relative of yours?’ I looked at him and said ‘Is this for your mother?’. ‘No, it’s for my wife’ he said, and luckily for me, just smiled...

First select your nurse

2007-02-12T16:55:00.000Z

We’ve been having fun with our nurse prescribing computer software this week. We couldn’t understand why when we selected a particular nurse’s name and purple prescription form that we always seemed to get the computer assuming it was for a community practitioner nurse prescribing from their restricted formulary (hence most items were coming up as blacklisted!).

Then we discovered under ‘precriber details’ on the computer that we had to select either independent prescriber, community practitioner nurse prescriber, or supplementary prescriber (we had assumed that the system would do this for us when we selected the correct precriber’s name).

I also discovered that the dispensary staff didn’t really appreciate the differences between the three categories of nurse prescriber so we killed two birds with one stone by finding out how to correctly enter a nurse prescriber onto the computer and ensuring that the staff really understood the differences between the types of nurse prescriber.

Top form

2007-02-09T14:58:00.000Z

I’ve seen from the pharmacy press that the draft revised version of the MUR form is now in circulation (see draft form at www.psnc.org.uk/advanced - comments required by February 28).

We’ve been waiting for this revised version before we start to implement MURs since we didn’t see the point in getting all the local GPs on board with the service only to have to go through it all again once the new form came out.

I am accredited to do MURs, but not having actually done one yet, I’m not the best person to comment on the proposed new form. However I have to say that it does look a lot better since I would predict that all GPs will want to see is the pharmacist action plan following the MUR. So hopefully the powers that be will get the new form agreed and in use as soon as possible.

In the meantime we are getting the premises accredited and the other pharmacists are also planning to get their accreditations. I personally liked the CPPE online accreditation but I know that at least one of the other pharmacists intends to attend a local training day where you receive the accreditation at the end of the days training.

Inspectors and everything else

2007-02-07T12:35:00.000Z

We’ve had a bit of an impromptu RPSGB inspectors visit this week. The inspector came to visit to check up on the premises (since the pharmacy has fairly recently relocated) and then started to go through everything else as well. Considering that we hadn’t prepared for the ‘everything else’ we didn’t do too badly.

We’ve collated all the points raised and drawn up an action plan that we will implement over time. The main points raised were around our (apparently) out of date SOPs for OTC sales and the general dispensing process (to add to the SOP for CDs) and how we analyse errors in order to stop them happening again.

We do keep a log of all near misses in the dispensary but we aren’t yet very good at spending the time analysing the log to see what the common errors are and how we can therefore improve the dispensing process. So this will keep us busy for a little while.

More interventions

2007-02-01T14:04:00.000Z

Here is my usual slot on some of the recent interventions we have made:

• Two asthmatic patients issued with acute scripts for erythromycin who were also taking theophylline. On contacting the relevant GPs, one was happy to halve the theophylline dose whilst the patient was taking the erythromycin, and the other GP wanted no action taken since the patient had recently had her theophylline checked and was at the lower end of the therapeutic range.

• One patient who was newly prescribed acamprosate at a dose of ‘2 QDS’. Following our conversation with the GP practice this was reduced to the usual dosage of ‘2 TDS’.

• A patient who had recently had an attack of gout and was not aware of leaving a gap before starting allopurinol and that the allopurinol was likely to precipitate a further episode of gout.

Handling CDs

2007-01-29T16:15:00.000Z

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

2007-01-25T09:54:00.000Z

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

2007-01-22T10:18:00.000Z

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

2007-01-15T10:41:00.000Z

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

2007-01-12T12:15:00.000Z

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

2007-01-08T12:31:00.000Z

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

2007-01-04T12:00:00.000Z

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!

2007-01-02T09:26:00.000Z

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.

Interesting reading

2006-12-30T16:14:00.000Z

I’ve just read our LPC newsletter and it makes particularly interesting reading this month.

They describe the pilot non-dispensing scheme and reiterate that while they don’t agree with it in principle (due to timing and why not concentrate on getting repeat dispensing up and running
instead?) they are encouraging contractors to take part in order to support the PCT in this initiative.

The newsletter also describes the LPC’s lack of progress with agreeing a SLA and funding with the local DAT for supervised consumption and that the LPC has a number of concerns with the C card scheme that I now know is being run in certain parts of the PCT.

These concerns boil down to the fact that the scheme SLA requires contractors to perform a number of tasks when clients come in asking for their free condoms, but there is no remuneration attached to this work (heard this before!).

Three day week

2006-12-28T11:07:00.000Z

It’s been great to have some time off over Xmas but the work is still all here to do when we get back, not least because all the dosette boxes that we fill for one of our care homes needed filling this week (of course!) which meant a considerable amount of staff time being taken away from the dispensary to enable us to get all this work done in the three days available to us this week.

We have recently done a lot of work both within the pharmacy and with the GP practices in order to really tighten up on our dosette box procedure (but that’s a story for another time).

Happy Christmas!

2006-12-23T11:34:00.000Z

As much as I enjoy my job, I’m pleased that Xmas week is nearly over. I wouldn’t say that it’s been the ‘manic hell’ that a lot of the pharmacy staff were predicting, but it has certainly been very hectic.

I think it’s made a difference that we have had a full week available to us in the run-up
to Xmas since there doesn’t seem to have been the usual smell of panic in the air!

We have an excellent Urgent Care Centre in the town next to us and so there has been no pressure on us to open over the Xmas period, and it’s great this year that the pharmacy staff will have three full days off over Xmas.

One of the dispensers told me she couldn't remember the last time that she didn’t work on Xmas eve. Anyway, I wish you all a very merry Xmas.

Agreement with GPs

2006-12-21T12:31:00.000Z

The boxes of biscuits, cakes and sweets have started to pour in from the customers, which is really lovely of them but really horrible for my waist line.

We have just been talking to our local GP practices about how we will handle scripts that come in for Prednisolone EC during the current ‘manufacturers delay’.

The PCT did email a circular round to all GP practices and pharmacies to alert everyone of the shortage and suggested a number of options of how this could be handled.

After talking to our GPs we have come to the agreement that any scripts we get in for the EC version where we are unable to supply, that we will give the GP surgery a ring to check that it’s OK to substitute the plain tablets and mark the script ‘PC’ etc.

The GPs don’t want us to automatically change everyone over onto the plain tablets in case particular patients have had stomach problems in the past (yes I know there’s not much evidence for the value of EC tablets v plain tablets!).

In these cases the GPs plan to co-prescribe a H2 antagonist or PPI depending on the severity of the previous stomach complaint.

This makes slightly more work for us, but I’m happy about it because from a liability point of view I don’t want to be in the position where we alter a script and the patient experiences stomach problems (even though there is a dubious evidence-base).

Repeat intervention

2006-12-17T11:49:00.000Z

Here are a few of the interventions I have made this week:

* The patient with numerous repeat medicines, which included two calcium
channel blockers. He had intended to take them both together so we contacted
the surgery to clarify which one the patient should be taking and which one
had been stopped.

* The lady who had recently had her blood pressure reviewed in outpatients
and had had her medication changed. However she didn’t know which of her
regular medicines were for blood pressure and of these, which she should
stop once she started taking the new ones from the hospital. So I advised
her to talk to her GP to make sure she took the correct ones, and stopped
the other ones appropriately (since one was a high dose of beta blocker).

* The patient recently issued a GTN spray who had been inhaling it rather
than spraying it under the tongue.

Do I come here often?

2006-12-14T11:23:00.000Z

Had an interesting encounter with a rather irate gentleman this week who came into the pharmacy asking for his wife’s repeat medication.

The counter staff couldn’t find anything on the shelf for him; the dispensary staff could see that she hadn’t had anything dispensed from us for 2 months; and on ringing the GP practice, the repeat prescription was not sitting over at the surgery.

So, despite his insistence, we were at rather a loss until one of the dispensary staff wondered if he was in the wrong pharmacy. So we rang the pharmacy up the road who informed us that this lady was a regular of theirs and that her medicines were all ready for her.

So we politely explained to the gentleman that he was in the wrong pharmacy and that his wife’s prescription had been dispensed elsewhere. All well and good, until he left the shop muttering ‘Well I can see why my wife never uses this pharmacy’. Ahhhhhhhh

Record returns

2006-12-08T11:37:00.035Z

The non-dispensing scheme is ticking along nicely. Most of the ‘non-dispensed’ items so far seem to be prn painkillers. I’ve also been talking to our locums who work in pharmacies which do have a few repeat dispensing patients and they have given me some great tips about where the system can potentially fall down with patients.

One ‘top tip’ is to stress to patients that once they decide they don’t need a medicine on their regular repeat, they can’t then change their mind at a later date. Therefore we have started to stress this as part of the non-dispensing scheme.

And sticking with the theme of ‘non dispensing’ and reducing drug wastage, we recently had a bit of a record with patient-returned medicines when we were given 19 unopened boxes of orlistat from one patient. I know that patients who request medicines they don’t actually need tend to do so either to ‘make sure they have enough at home’ or because they want the doctor to think they are dutifully taking their medicines.

However, we were quite amazed at how this patient had managed to accumulate nearly 2 years worth of this drug, since they should have been regularly monitored as part of a weight loss programme.

Money for nothing

2006-12-06T09:37:00.000Z

We have started to take part in a PCT-led non-dispensing scheme, where we basically get paid more to ‘not dispense’ rather than to dispense. I believe that the LPC reluctantly agreed to the scheme because it is after all, new monies for pharmacy.

However I share the LPCs’ concerns that a) this is a rather busy time of year to start anything new, and b) whilst the PCT needs some ‘quick wins’ to show some savings to the drugs budget, it would be strategically better if they worked with the local GPs to get repeat dispensing up and running, since the under repeat dispensing we are required to check if patients need all their repeat medicines anyway.

There is also a firm evidence-base that repeat dispensing does reduce drug wastage.

Never-the-less we are duly taking part and are required send a list of the ‘non dispensed’ items to the PCT in order to receive payment. If nothing else, it has really made us think about the practicalities of beginning repeat dispensing in the pharmacy.

Under our terms of service, we are obviously ready to take this on but there’s nothing like actually starting it and finding out where the strengths and weaknesses of our planned procedures actually lie.

Secret C Cards

2006-12-01T10:41:00.000Z

Had a really embarrassing encounter with a young man this week who came into the pharmacy and presented me with a ‘C card’. I simply hadn’t come across this before and neither had any of the other staff in the shop.

So I asked him what he expected me to do now he had shown me the card and he said that he expected to be given free condoms adding ‘This is a chemist isn’t it!’.

It was at that point that the penny dropped (I have heard of these schemes before) and on looking at the card I could see that it was from a town some distance away from ours that, prior to 1st October, had been in a different PCT.

So I explained to him that we weren’t taking part in the scheme and advised him to try one of the pharmacies in the town from where he had picked up the card.

I was just really frustrated at the lack of communication about this scheme (e.g. Was I supposed to know about this? Was there sufficient information available to patients to explain which pharmacies were taking part?), and that this young man had been responsible enough to try to discretely use the scheme and had failed!

I just hope that our encounter didn’t put him off and that he does try to use scheme again. I have since clarified that the scheme is currently just running in the aforementioned town.

Learning to use skills

2006-11-29T14:35:00.000Z

We have really started to get to grips with using the skills of our recently qualified checking technician to best effect. We had started trying to use these skills with patients waiting for scripts but found this to be difficult because it can be hectic and inevitably she had already had something to do with the labelling and assembly of the prescription by the time it needed checking.

So we have started to use her skills to greatest effect when we prepare the repeat prescriptions we have collected. For these prescriptions we make sure that a pharmacist assesses them first, other dispensary staff label and assemble them, and then our checking technician can check them all off.

This really is team work to its best effect and once the PCT can persuade the local GPs to start implementing repeat dispensing we will be able to use the skills of the dispensary team even more.

That'll teach me!

2006-11-26T15:46:00.000Z

I had hoped to attend an evening training session this week for new pharmacists wishing to become accredited for the PCT EHC PGD scheme. These sessions are run by the PCT every 4-6 months.

I duly completed my CPPE open learning pack and booked some annual leave to ensure I could get to the event on time. However, on faxing my confirmation of attendance to the PCT I was immediately told by them that this event had been cancelled due to lack of numbers, and I would need to wait for the next one.

I do appreciate the need to cancel events that are poorly attended, but I was slightly irritated we hadn’t been proactively informed.

Behind bars

2006-11-23T10:33:00.000Z

Had a couple of interesting comments from you regarding the patient we recently barred from using the pharmacy (see Taking a Tough Line).

One comment asks if we can actually do this within our terms of service, and another suggests that we can as long as we direct the patient to an alternative source of pharmaceutical services (there is another pharmacy a few doors along from us).

Well I’ve had a look at the online NPA Information Database for advice and it states that ‘the NHS (Pharmaceutical Services) Regulations 2005 now mean that a pharmacist may decline the supply of a medicine in certain circumstances’, with one of these circumstances being where ‘the pharmacist or other persons on the premises are subjected to or threatened with violence by the person presenting the prescription form’.

It also states in the Medicines, Ethics and Practice Guide (albeit in the section concerning services to drug misusers) that ‘pharmacists may decline to provide a service to a patient whose conduct is unacceptable’.

So hopefully that helps to clarify things. I appreciate the comments that have been fed to me on this.

About a child

2006-11-20T11:06:00.000Z

I’ve had some interesting OTC consultations recently. For example:

• The mother who brought her 15 year old son into the pharmacy to buy some sleeping tablets. Apparently her son hadn’t been sleeping properly for three weeks and wanted something to help. I asked what they thought could be causing the sleepless nights but I got the distinct impression that he wasn’t going to tell me with his mum there.

So I printed off the PRODIGY PIL on insomnia and asked them to follow the advice in there before resorting to OTC sleeping tablets. I haven’t seen them since but whether that’s because the problem is cured or they have gone elsewhere to buy some tablets, I simply don’t know.

• The mother who brought her 11 year old in with monthly migraines. It seemed that these were linked to the onset of menstruation and she had been to the GP practice to ask for advice since it usually ended up in her daughter being sent home from school in tears once a month.

The GP had simply recommended pain killers for the time being and I felt mum was after some further reassurance. So again I used PRODIGY to print off the relevant PILs and recommended some quick and easy painkillers that the daughter could take to school to use as soon as she felt the onset of the headache. So we will wait to see how she gets on next month.

Reboot when busy

2006-11-18T12:12:00.000Z

Had a nightmare this week when the computer system started to get rather twitchy and then crashed!

We battled with it during two very busy days of dispensing and all we could do was keep apologising to everyone for the delays.

The main problem boiled down to the labels being printing out – either not at all, or with no quantity on them, or worst of all, with a completely different patient name to the one that we had entered.

The software company were pretty good at getting it sorted out, but it was the last straw when they kept asking us to re-boot the system at our peak time of dispensing.

The whole pharmacy team ended up very stressed and my usual wine consumption has definitely doubled this week.