Beneficial check of unwanted medicines

The pharmacy contract stipulates that each pharmacy should participate in two clinical audits per year, at least one of which should be practice based and one determined by the local primary care trust.

We have conducted an audit of interventions identified from NHS prescription repeat lists collected from a GP surgery (with patients’ consent).

The aims of the audit were;

• To benefit patients and prescribers
• To enhance pharmacy’s role in terms of reducing potentially unnecessary prescribing
• To build a positive rapport with patients and prescribers by interventions
• To allow a preregistration trainee experience and active involvement in the Audit process

Method

Pharmacists perform clinical checks by looking at computerised patient medication records (PMRs). If a medicine has not been ordered for several months we assume it has been stopped, but we cannot identify from the PMR if the patient should be still taking it. NHS prescription repeat forms can sometimes give better understanding of a current medication regimen than the PMR.

Advice was sought from the National Pharmacy Association to ensure the legal and ethical position of reviewing NHS prescription repeats before patients come to collect their prescriptions. The NPA advised us that because our intention was in the patients’ best interests the audit was within ethical and legal boundaries.

The audit was conducted over a two-week period where repeat prescriptions collected from a GP surgery were reviewed by the pharmacy. Before patients visited the pharmacy to collect their prescriptions, the pharmacy was able to identify the lines that the patients were not ordering. These could be:

• Items which had been stopped by the GP or specialist but which the GP had not yet cancelled from the repeat list. This could lead to incorrect medication being prescribed in the future.
• Medicines that were regular but which the patient had not recently ordered due to either confusion, believing that they are no longer needed, or poor compliance. Either of these reasons should lead to an intervention or medicines use review.

We spoke to patients whose regular medicines were not ordered but still on the repeat list. With the information we received we communicated with the GP surgery.

If a medicine had been stopped by the GP or specialist we asked the surgery to remove it from the repeat list in order to avoid confusion in the future.

We also suggested an appropriate  response from the GP surgery when a patient misunderstood their treatment. The surgery responded with action that would be taken or had been taken to enable the pharmacy to  track the patient’s future care.

Results

In the two-week period we reviewed the repeat forms of 650 patients and made 51 interventions. As a result of these, 32 items were identified that needed to be deleted from repeat medicines lists and 26 interventions required referral to the patient’s GP

After identifying medicines that patients were not ordering, we determined the reasons. Some patients stopped taking some medicines because of confusion or ignorance, for example:

• A patient stopped using his Spiriva Inhaler because he believed the hospital had said to
• A patient stopped taking metformin because he understood his new tablet sitagliptin was replacing it when it was prescribed to be taken in combination
• Some patients did not order preventer inhalers (this required intervention for re-education on inhaler use or referral to asthma nurse)
• A patient had not ordered GTN spray for over two years but carried an out-of-date one
• A patient stopped taking dypiridamol retard because the capsule was too big to swallow
• Patients stopped taking aspirin 75mg, ACE inhibitors, bisphosphonates, calcium or diabetes tablets on account of negative feelings
• A patient on insulin was not ordering lancets (suggesting these were being reused)

Some medicines were not being ordered because of their side effects, for example, metformin owing to gastrointestinal side effect, and simvastatin owing to muscle cramps.

Other medicines were not ordered because of administration errors, for example:

• One patient being treated with methotrexate was not taking folic acid 5mg weekly (which the hospital prescriber had recommended) because it had not been added to the repeat medicine list
• One patient taking two 500mg lanthanum tablets three times daily was referred so that he could be prescribed the cheaper 1,000mg tablets

Items that we found were on repeat lists but which were no longer needed were requested to be cancelled, therefore preventing wasted medicines and avoiding the possibility of prescribing errors. These included:

• Glucose monitoring strips and lancets
• Colostomy items
• Antidepressants
• Eye drops for glaucoma
• Analgesics
• Iron tablets, folic acid, vitamins
• Creams

Conclusion

Overall the audit was considered a success and we achieved our aims in the following ways. We spoke to patients about their treatment and we were surprised how much some of them appreciated our efforts. We built a strong rapport with patients. We found that patients for whom we carried out an intervention trust pharmacist’ expertise more than others regarding their treatment. It is possible that this might lead such patients to access other services, like the new medicine service.

The surgery provided us with feedback on cases where they needed to contact patients regarding the issues identified. The surgery appreciated the pharmacy’s efforts for patients; this could, as a consequence, lead to good progress towards the primary care trust’s  QIPP (quality, innovation, productivity and prevention) target.

The preregistration pharmacist trainee got involved actively and identified the areas she needs to develop more.

Since our audit was carried out, the pharmacy has been actively checking patients’ repeat lists to identify any areas that require intervention. In this way, we could reach our yearly 400 medicines use review target after only nine months.