PHARMACY INTERVENTION RECORD FORM 1.7 Medicine

Transcription

1 Date / /20 Pharmacist initials Ward Patient Demographics (as Hospital Number) Point Admissions (A) Care of the Elderly(CE) Respiratory (R) Gastroenterology(G) Rheumatology (Rh) Endocrine (E) Other (o) Use Codes if outlier on the ward Reconciliation Inpatient Stay TTO Transcription Other Time Impact Outcome Action Reason Type Drug See Codes on next page Dose adjustment Route Change Stop drug Add Drug Change Drug Stop/review date Monitor Endorsement Completion/ rewrite of prescription. Provide Information Subtherapeutic Supratherapeutic Drug interaction Drug -disease interaction Allergy Adverse drug reaction (or risk of) TDM Compatibility Patient Preference Patient Adherence/ Education Ambiguous prescription Illegal prescription Drug Missed Untreated Indication No indication Duplication Formulary/ protocol adherence Cost Effectiveness VTE Other (Describe on next page) Prescriber contacted Nurse contacted Documentation in notes Self Other (describe on next page) Advice ignored Advice acted on Acknowledged no action Information only Low Moderate Significant (Extended Intervention) (Datix) < 5 minutes 5-15 minutes minutes 30minutes< Developed by Will Hall Reviewed by Doris Mensah and Annett Blochberger on 12/11/11. Review by [DATE]

2 Drug Involved Risk Anaesthetics (An) Antiretrovirals (ARV) Intrathecal (IT) Sympathomimetics (Sym) Antibiotics (AB) Cytototoxic (CT) Lithium (Li) Tuberculosis (TB) Anticoagulants (AC) Immunomodulatory (I) Opiates (OP) Vaccines (VC) Other Antidiabetics (Dia) Insulin (In) Oxygen (O2) Per System Gastrointestinal (GIT) Infection other (IO) Malignant Disease (MD) Ear, Nose and Orapharynx (ENT) Cardiovascular (C) Contraceptives (CT) Nutrition and Blood Local Anaesthetics (LA) (Nut) Respiratory (Rp) Endocrine (End) Musculoskeletal (MS) Skin (Top) Central Nervous System (CNS) Obstetrics and Gynacology (OG) Eye (Oc) Impact Assessment Matrix Likelihood Almost Certain Expected to occur at least daily Likely Expected to occur at least weekly Possible Expected to occur at least monthly Unlikely Expected to occur at least annual Rare Not expected to occur for years Consequence if intervention not made. Insignificant Minimal injury No need for medical intervention. Moderate Minor requiring medical assessment increase in hospital stay in 1-3 days sub optimal treatment Single failure to follow standards/ guidance /policy. Significant Moderate requires immediate assessment. Increase in length of stay by 4-15 days. Significantly reduced effectiveness of treatment. Multiple failures to follow standards/ guidance /policy. Moderate Significant Significant Major would lead to incapacity/disability/long term effects increase hospital stay over 15 days Non-compliant with national standards or legislation. Low Moderate Significant Significant Catastrophic would lead to death Totally unacceptable level of treatment Complete failure to follow national standards/legislation. Low Moderate Moderate Significant Significant Low Low Low Moderate Moderate Record of Intervention that did not fall under any Categories. Hospital Number Dataset other category chosen Suggested New Category Developed by Will Hall Reviewed by Doris Mensah and Annett Blochberger on 12/11/11. Review by [DATE]

3 Records of Extended Intervention Pharmacist Completing Developed by Will Hall Reviewed by Doris Mensah and Annett Blochberger on 12/11/11. Review by [DATE]

4 Records of Extended Intervention PHARMACY INTERVENTION RECORD FORM 1.7 Medicine Pharmacist Completing Developed by Will Hall Reviewed by Doris Mensah and Annett Blochberger on 12/11/11. Review by [DATE]

5 Explanatory Notes 1. Complete the top left hand corner of the sheet once attending an individual ward. Date / /20 Pharmacist initials 2. One sheet to be used per ward and per day. 3. Complete the date, initials and the wards speciality by ticking the appropriate box.. Cardiology (C) Cardiac surgery (CS) Neurology (N) Neurosurgery (NS) Stroke (S) Other (o) 4. If the ward has outliers or has a range of specialities, the box should be ticked corresponding to the speciality with the most patients on the ward. Use Codes if outlier on the ward 5. Each time one intervention is made, one column should be completed. 6. The Codes can be used to identify patients who are outliers or those that differ from the predominant speciality. To highlight these patients the use codes if outlier on the ward section should be used. Each speciality has a code which can be annotated into the column that patches each patient. Eg for Cardiology outlier enter C, if the ward is a Cardiac Surgery Ward. Cardiology (C) Cardiac surgery (CS) Neurology (N) Neurosurgery (NS) Stroke (S) Other (o) Use Codes if outlier on the ward Use Codes if outlier on the ward C 7. The patient s hospital number should be entered into the next row. 8. As mentioned before, one column should be used per intervention. Therefore if multiple interventions are made for one patient, the patient demographics will need to be repeated as needed. An example can be found on the next page, of one patient with 3 examples.

6 Date / /20 Pharmacist initials Patient demographics (Hospital number) Cardiology (C) Cardiac surgery (CS) Neurology (N) Neurosurgery (NS) Stroke (S) Other (o) A A A Once a patient s hospital number has been filled in the rest of the sections will need to complete corresponding to the point the intervention was made, drug involved, type of intervention, reason for intervention, action taken, result, impact and time taken. 10. The 1 st section Point outlines which stage of the patients episode that the intervention was made. There are 4 possible choices. a. Reconciliation - 1 st contact with pharmacy, when a drug history is taken and chart first screened. b. Inpatient Stay - Interventions made as inpatient not including reconciliation or TTO. c. TTO - Interventions made at discharge/ preparation for discharge. d. Transcription Interventions made, when a chart is rewritten. e. Other - Interventions made for outpatients or patients not being admitted as inpatients (including PCT and MI enquires). 11. The 2 nd section highlights which group or class of drug this intervention involves. a. Unlike the other sections a tick is not required instead a drug code is used. The key to the drug code is found on page 2, but I repeat it partially here to facilitate explanation. Risk Anaesthetics (An) Antiretrovirals (ARV) Intrathecal (IT) Sympathomimetrics (Sym) Per System Gastrointestinal (GIT) Infection other (IO) Malignant Disease (MD) Ear, Nose and Orapharynx (ENT) b. The code used should be chosen from the list above. c. The code is the letters in the brackets after the corresponding drug class.

7 d. If a medicine falls under one of the categories in Risk Medicines, the code from this group should be used. e. If a medicine does not fall under one of the categories in Risk Medicines the per system code should be used. f. Under no circumstances do both codes need to be entered into the table. 12. The 3rd section is Type, this section clarifies what was requested in the intervention. This table outlines the parameters of each option with illustrated examples. Term Definition Examples Dose adjustment Change in the dosage regimen, can be an increase or decrease in dose or frequency. Decreasing dose due to poor renal function, increasing dose as patient response is unsatisfactory Route Change Changes in the route of administration Changing antibiotics IV to PO, Changing liquids from PO to NG. Stop drug Medication to be stopped Antibiotic Courses completed. Add Drug Medication to be started Addition of ramipril post-mi Change Drug Stop/Review Date Monitor Endorsement Complete/ rewrite prescription. Provide Information Medication to be replaced with a different medication, for the same indication. Change in the planned duration of a treatment Keep track of an issue. Addition of information to the drug chart NOT including BNF warnings Prompting doctor to complete a prescription or rewrite a prescription. Give information to a member of the MDT or patient either verbally or written. Lansoprazole instead of Omeprazole as patient has hyponatremia. Dual antiplatlet use after an STEMI, ensuring the correct review date is added to the chart. Monitor TDM medicines, monitoring particular blood tests or other parameters such as blood pressure. Annotation of how to administer medicines via NG. Prescription not signed. Counselling a patient on a high risk medication. Answering queries from the MDT. Advising a doctor on how to start an IV infusion of heparin including dosing.

8 13. The next section is the reason for intervening. The option should be ticked that best represents the precipitating factor prompting the intervention. Again here are the options, parameters and some examples. Term Definition Examples Subtherapeutic Supratherapeutic Dose too low/inadequate. Include frequency Dose too / toxicity/ Include frequency Patient prescribed Co-codamol 30/500 TDS and using oral Morphine TDS. Increasing the Co-codamol to QDS Metronidazole and Co-Amoxiclav, co-prescribed. Patient in renal failure, requires does reduction. Drug interaction Medication added or stopped that interacts with another medication. Calcium supplement and alendronic acid, change times to prevent interaction from occurring. Drug- disease interaction Medication added that is contra-indicated or cautioned in a patient s pre-existing disease. NSAIDS in asthmatic patients; Amitriptylline post- MI Allergy Patient allergic to a prescribed medication. Patient allergic to Aspirin prescribed Ibuprofen. Adverse drug reaction (or risk of) Patient is experiencing or at risk of experiencing a side effect. Patient has previously experienced an ADR, and drug is prescribed, recommended alternative. Patient on opiates, co-prescribe Laxatives. TDM Medication requires TDM. Vancomycin, Heparin, Warfarin. Compatibility Issues with chemical or physical compatibility of two medications to be combined in situ. Y site compatibility, additive compatibility. Patient Acceptability Perceived that patient may prefer an alternative treatment regime. Can include dose, route, drug. Patient prefers liquids due to swallowing difficulties.

9 Term Definition Examples Patient adherence/ education. Could improve patient s ability to take their medication. Will help a patients understanding of their medication. Patient forgets to take Simvastatin at night, change to atorvastatin. Ambiguous prescription Prescription is unclear/ open to interpretation/ illegible. Poor handwriting. Illegal prescription Prescription is incomplete Not signed. Drug Missed Drug forgotten unintentionally on reconciliation or transcription. Reconciliation or on admission. Untreated Indication Condition requiring treatment. Prevention of osteoporosis in patients on long term prednisolone No indication Drug not needed Proton Pump Inhibitor not reviewed after a patients NSAID has been stopped. Duplication Same therapeutic class, or same drug. Lansoprazole and Ranitidine co-prescribed. Formulary/ protocol adherence Medication prescribed does not follow local, national policy/ formulary. Patient prescribed Lecardipine changed to Amlodipine; use of Pain Guidelines. Cost Cheaper treatment available. Change Atorvastatin 10mg ON to Simvastatin 40mg ON. Effectiveness More Effective treatment available. Changing Acyclovir from PO to IV in Encephalitis. VTE Any intervention relating to VTE risk assessments or any assositaed prescription. Prompting a doctor to sign a VTE risk assessment form. Other (Describe on next page) 14. The 5th section is Action, this describes the activity carried out by the pharmacist to resolve the cause of the intervention. The options may be used more than once per intervention but are limited to a. Prescriber contacted issue discussed with a prescriber. b. Nurse contacted issue discussed with a nurse.

10 c. Documentation in Notes Issue documented in notes. d. Self Issue resolved by the pharmacist completing form. e. Other (describe on next page) See point The 6 th section is outcome, this describes the response of the individuals involved in actioning the intervention made by the pharmacist and include a. Advice Ignored Staff member aware of advice but does not act on it. b. Advice Acted on Staff member acknowledges and actions intervention. c. Acknowledged no action Staff member aware of advice but does not act on it after discussion? d. Information Only Advice given for information only. 16. The 7 th Section is the impact, this describes the perceived organisational impact of intervention, based on likelihood of reoccurrence and consequence if intervention not made. A risk matrix has been produced to support this. Likelihood Almost Certain Expected to occur at least daily Likely Expected to occur at least weekly Possible Expected to occur at least monthly Unlikely Expected to occur at least annual Rare Not expected to occur for years Consequence if intervention not made. Insignificant Minimal injury No need for medical intervention. Moderate Minor requiring medical assessment increase in hospital stay in 1-3 days sub optimal treatment Single failure to follow standards/ guidance /policy. Significant Moderate requires immediate assessment. Increase in length of stay by 4-15 days. Significantly reduced effectiveness of treatment. Multiple failures to follow standards/ guidance /policy. Moderate Significant Significant Major would lead to incapacity/disability/long term effects increase hospital stay over 15 days Non-compliant with national standards or legislation. Low Moderate Significant Significant Catastrophic would lead to death Totally unacceptable level of treatment Complete failure to follow national standards/legislation. Low Moderate Moderate Significant Significant Low Low Low Moderate Moderate a. To use the risk matrix the likelihood of reoccurrence and consequence of the intervention not being completed must be decided. b. Likelihood involves the possibility of this reoccurring in the trust

11 c. Consequence corresponds to either length of hospital stay, need for medical intervention, effect on treatment, non-compliance with procedures, protocols, standards and legislation. d. The Matrix can be found on page 2, but I have repeated here to aid explanation. e. Once appropriate Likelihood and consequence is chosen, use the matrix to select the impact assessment. Eg if Likelihood is possible and Consequence is Moderate, impact is Significant. f. If the Impact is a DATIX form should be completed g. If the Impact is Significant an Extended Intervention form should be completed, see section The 8 th section is time taken to complete, and corresponds to time taken to carry out intervention in minutes. 18. An additional section on page 2 should be used if the category other has to be chosen in any of the sections of the form. a. In this case the patients hospital number, section detail need to be added. b. Furthermore the suggested new category section will need to be completed outlining a suitable category descriptor. Eg Hospital Dataset other Number category chosen Suggested New Category A Reason Funding Request For PCT. 19. Extended intervention forms need to be completed as outlined in point 16. a. The Pharmacist completing box needs to completed with the pharmacists full name, b. should be the speciality that the patient is under Pharmacist Completing c. Hospital Number of the patient d. Drug involved

12 e. Date of intervention. f. Main section should include the details of the intervention made, including what prompted the intervention, what was done to resolve the issue and who else was involved in solving the issues.