Annual Medicines Management Report. 2013 to 2014

Annual Medicines Optimisation and Pharmaceutical Services Report 2014/2015 Annual Medicines Management Report 2013 to 2014 Date Presented to: Action Plan included Review Date of Action Plan May 2014 Patient Safety Group July 2014 Yes November 2014 Date of Next Annual Report Author Ed England, Medicines and Research Manager May 2015

Annual Medicines Optimisation and Pharmaceutical Services Report 2014/2015 1. INTRODUCTION... 1 2. CURRENT POSITION... 1 Strategy, risk and governance... 2 Safe use of medicines.... 3 Effective choice of medicines... 5 The patient experience... 6 Environment for medicines optimisation... 7 Workforce for medicines optimisation... 8 3. RISKS IDENTIFIED... 9 4. PROPOSED MEDICINES MANAGEMENT PROGRAMME 2014/15... 9 5. APPENDICES... 5.1 Appendix 1: Medicines Management Programme 2012/2013... 9 5.4 Appendix 2: Summary of declarations of Controlled Drug concerns... 13 5.6 Appendix 3: Medicines Management Programme 2013/2014... 16

INTRODUCTION The annual medicines management report for South Central Ambulance Service outlines the progress against the 2013-14 programme. The report aims to assure the board that the organisation complies with Care Quality Commission essential standard outcome 9: management of medicines, medicines legislation and guidance, is developing best practice. The structure of this report is based on the Trust Development Authorities Medicines Optimisation and Pharmaceutical Framework, which has been slightly adapted by the Ambulance Pharmacists Network. Medicines optimisation has four strands: understanding the patient's experience, evidence based choice of medicines, ensuring medicines use is as safe as possible and making medicines optimisation part of routine practice. CURRENT POSITION The medicines management programme for 2013/14 together with the progress and outstanding actions is at Appendix 1. A discussion of the key issues is summarised in this section and was scored by the Medicines Group a subgroup of the Clinical Review Group. 1

Strategy, Risk and Governance The Trust has a strategy for the development of medicines optimisation and has policies and professional advice in place. There are some development needs in this area, and the actions below would improve the Trusts performance. Actions required Make medicines policy available to staff at induction, and audit compliance with policy; Develop a robust process to manage clinical risk and costs associated with medicines; Improve upward information to Board members about medicines use. 2

Safe Use of Medicines The Trust pharmacist audits the safe and secure handling of medicines each year and this is presented to the Quality and Safety Group. Recommendations of the audit are not always implemented and this year responses and action plans were not received from Kidlington, Newbury, Oxford City and South Oxfordshire (the latter two for the second year in a row). Medicines errors are reviewed by the Medicines Group and are reported formally through the Clinical Review Group (and from July 2014 through the Patient Safety Group). The number of serious remains low however to ensure practitioner and organisational learning from errors in the administration of medicines a refection is requested from the staff involved in medicines incidents and these are collated in a quarterly report. Cost reducing schemes have not been implemented in the Trust, though there is no formal evaluation of schemes to reduce investment into current systems. The Trust medicines policy defines the responsibilities of staff for the safe use of medicines; Patient Group Directions (PGD), protocols and guidelines for all clinicians are in place and regularly updated. The PGDs for Emergency Care Practitioners were reviewed during the year and a diazepam tablet and prochlorperazine PGD were introduced. The annual audit continues to show that Area Managers need robust processes to sign off staff as competent to use PGDs and so in 2014 an e-learning package with an assessment will be implemented. 3

The PGDs for ketamine and midazolam have not been implemented; the agreed learning for these medicines is in three steps: 1. working with a medical prescriber; 2. telephone support from a medical prescriber; 3. independent practice. The air ambulances have implemented their own systems and therefore an audit of medicines storage standards and medicines use needs to be undertaken. Contracted private ambulance providers administer medicines to Trust patients and a medicines management section has been added to the contract and discussions now take place with the contractors. The term off label is used to describe medicines which are not used in accordance with their licence. The Trust does undertake a risk assessment of all medicines which are introduced to the Trust, but a formal policy is not in place. For PGDs the off label status is highlighted to staff, though this is not the case for medicines which form part of the AACE guidelines. Actions required Circulate anonymised medicines error reflections once a month to team leaders and educators, so that learning can be shared with clinical teams; Implement patient charging for supply of PGD medicines; Implement e-learning for ambulance PGD medicines (codeine, paracetamol intravenous and tranexamic acid); Implement step 2 of the training for the midazolam and ketamine PGDs; Audit standards of medicines management at air ambulances; Review and audit private ambulances adherence to Trusts medicines management specification; Formalise a policy for the safe use of off-label medicines. 4

Effective Choice of Medicines The Medicine Group discusses medicines issues. Costs and quantities of medicines used are monitored, and when the electronic patient record is developed area team data will be able to be sent to area managers. During 2013 dexamethasone for croup and the antihistamine loratadine were introduced for nurses, paramedics and technicians, and Syntometrine for the management of postpartum haemorrhage by paramedics and nurses was rolled out across Berkshire, Buckinghamshire and Hampshire. Activated charcoal for overdose has also been introduced, and this is in accordance with the recommendation of the NICE Self Harm Clinical Guideline 16. An e-learning package has been released for dexamethasone and the management of postpartum haemorrhage and is in testing for activated charcoal. Audits this year included the use of tranexamic acid and intravenous paracetamol by paramedics and ambulance nurses and the management of urinary tract infections by Emergency Care Practitioners. Prescribing continues to be at low levels and is reviewed at the Medicines Group. The Trust pharmacist worked with the Hampshire heath care teams to develop the current Hampshire and Isle of Wight antibiotic formulary which is the basis of the Trusts antibiotic PGDs. The formulary is currently being updated. The UK Ambulance Services Clinical Practices Guidelines 2013 were implemented on 01 April 2014, which mainly involved minor changes in practice. 5

The Patient Experience There is a policy in place for the administration of patient s own medicines on an ad hoc basis. In 2014 the plan is to implement telephone support from the Clinical Support Desk to support and enable ambulance clinicians to safely administer patients own palliative care medicines. Medicines information training has been delivered to a small number of 111 Clinical Advisors and no Clinical Support desk staff. The Clinical Support Desk clinicians provide advice to patients on how to take their medicines however there are no formal guidelines to triage and enable patients to administer their own medicines. Medicine modules contain original packs of medicines which include a patient information leaflet to enable clinical staff to support patients to take their medicines. The Trust PGDs include information for paramedics and nurses to share with patients. The Trust undertakes limited monitoring of medicines use and this year audited the use of tranexamic acid and intravenous paracetamol. The development of electronic patient records will enable this to be developed and fed back to Area Managers. The Trust supports hospital reconciliation of patient s medicines, which has been demonstrated to improve care. The Trust has worked with hospitals across South Central and provides Green bags on all vehicles so that patient s medicines can be taken to hospital. Audit across the health economy has demonstrated that the use of the Green 6

Bags by ambulance clinicians is low and an awareness campaign is needed. Action required Telephone support for the administration of palliative care medicines; All Clinical Advisors require medicines information training; Develop and audit a policy for the Clinical Support Desks to triage and enable patients to take their own medicines; Explore the feedback of medicines use information to area managers; Green Bag Awareness campaign. Environment for medicines optimisation Most medicines have been risk assessed for appropriateness for the environment in which they will be administered, but this is not audited and regularly reviewed. Risk assessments and Intravenous guidelines have been rolled out for the wider range of medicines used by BASICS doctors and this is updated as new medicines are requested. The Trust has web-based software to manage the packing of medicines modules and a retrospective record of the medicines administered by individual clinicians is maintained. The system requires maintenance and there is the potential to develop reporting from the system 7

and link with the electronic patient record (planned for late 2014). The summary of the declaration of Controlled Drug concerns to NHS England is at Appendix 2. Incidents are monitored monthly by the Integrated Performance Review and the numbers are comparable with other ambulance trusts. The Trust pharmacist audits the management of morphine at each ambulance site once a year and this is reported in the in the Medicines Management Audit Report 2013/2014. The role out of the policy for the Management of Controlled Drugs was delayed due to a legal change which requires Hospitals to have a Home Office licence to supply morphine to ambulance trusts. Consequently an adapted process is being rolled out in Hampshire, and is planned coincide with the opening of the South East Resource Centre. Action required Implement Trust policy for the safe management of morphine across Hampshire; Agree Service Level Agreement for the direct supply of morphine to Paramedics and BASICS doctors in Hampshire (subject to Home Office Licensing); Develop e-learning on the safe and secure management of morphine. Workforce for medicines optimisation 8

A workforce plan to support the delivery of medicines optimisation is required. The Trust employs a pharmacist to provide pharmaceutical advice and it would be useful to link the medicines optimisation plan to the Workforce Board plans. This would highlight mandatory and patient safety medicines education requirements and the need to develop a strategy for non-medical prescribers. There is some medicines training for staff, however competency assessment is in development in most areas and there is no ongoing mandatory training. The Safety Alert Broadcast on Injectable Medicines (NPSA 20) suggested that an annual update of injection technique should be in place; updates on medicines administration does not take place and practitioners recruited from other Trusts are not assessed for competence. An e-learning package needs to be developed to enable all staff to have access to this training. The pharmacist leads the medicines induction training for paramedics and nurses as well as an annual meeting for non-medical prescribers. Clinical staff receive some training and updates on medicines to keep them abreast of developments and this includes a monthly Questions and Answers column in the staff e-newsletter, e-learning modules (as previously discussed) and voluntary workshops. Medicines optimisation should be developed as part of mandatory training for all clinical staff. Area Managers are responsible for the management of medicines locally, and this requires knowledge of medicines optimisation, safe and secure management of medicines as well as medicines use locally. The training needs of this staff group needs to be assessed. Action required Pharmacist advice to Workforce Board to highlight mandatory and patient safety medicines education requirements Strategy for the development and monitoring of non-medical prescribers. Develop e-learning package for the safe administration of medicines; Medicines optimisation should be developed as part of mandatory training for all clinical staff. Assess Area Managers medicines related training needs. 9

3.0 RISKS IDENTIFIED The following risks were identified in this annual report and are the same as in last year s report: a. Air ambulance has developed own system for managing medicines and this requires auditing; b. Area Managers do not appear to have a process for the sign off of Patient Group Directions; c. Annual update on the safe administration of injectable medicines is required, but a process is not in place; d. Clinical Advisors require training in answering 111 medicines information enquiries. 4.0 PROPOSED MEDICINES MANAGEMENT PLAN 2013/2014 The proposed medicines optimisation and pharmaceutical services plan for 2014/2015 is at Appendix 3. The actions identified in section 2 informed the Plan. The Boards approval of the medicines optimisation and pharmaceutical services Plan 2014/2015 is requested. 10

Objective 1. Medicines Management Policy The Trust must produce an annual Medicines Management programme with clearly defined objectives and progress The Trust must produce an annual Medicines Management report 2. Procurement South Central Ambulance Medicines Management Programme 2013/2014 Actions Medicines Management Programme 2013/2014 Appendix 1 Standard operating procedures developed for Hampshire Morphine Processes Attached Procurement of medicines must be in line with the Trust Medicines Management Policy 3. Safe and secure management of medicines The storage of medicines must be in line with the Medicines Management policy Investigated option for direct delivery by hospitals/industry Direct supply of prefilled syringes to Oxford agree but not implemented Medicine modules up to date with agreed medicines. Ongoing lack of engagement with medicines audits in some areas of the Trust (South East, South West, North East, North South) Medicines management audited at Thruxton but not at Benson air ambulance base. 4. Prescribing Prescribing must be in line with the Trust Medicines Management Policy Prescribing policy, improved monitoring and strategy for the professional development of non-medical prescribers is still required. 11

Objective 5. Supply and administration of medicines Administration of medicines must be in line with the Trust Medicines Management Policy Develop protocols and Patient Group Directions to standardise and improve appropriate access to medicines. Ensure staff have appropriate training for the safe administration of medicines Actions Protocols developed for charcoal and dexamethasone. Both medicines rolled out in October with an e-learning package for dexamethasone. E-learning package now being developed for activate charcoal, at the request of staff. Audit the medicines supplied to BASICS doctors. Syntometrine rolled out across the Trust in October, together with an e-learning package. Tramadol and the associated PGD for nurses withdrawn as morphine is now available. Implement patient charging for supply of PGD medicines Step 2 of the training for the midazolam and ketamine PGDs not rolled out, s Trust happy with telephone support. This needs to be reconsidered in 2014. Audit of sign off Patient Group Directions by Area Managers has shown that process is not robust. An e-learning package will be developed in 2014. The e-learning package for the safe administration of injectable medicines (NPSA 20) was not developed as this was to be part of face to face training. This has not been implemented and so will be reopened as an action. Pain Management Tool to be rolled out as part of pain review in 2014. 6. Medicines information To enable professionals providing clinical advice by telephone to interpret medicines information resources Medicine information training delivered to some 111 Clinical Advisors in the North, but none in the South. A more robust process is enquired. 12

Objective 7. Safe and secure management of Controlled Drugs The management of Controlled Drugs will be in line with the Medicines Management Policy 8. Implementation of policies There must be a system for the co-ordination, ratification and implementation of guidelines and policies related to medicines in the Trust 9. Medicines related risks Develop clinical staff understanding of medicines related risks 10. Error reporting and learning from experience Learning from medication errors and near misses (including any resultant changes) to be shared across the Trust Actions Policy for the Safe management of morphine policy updated to enable station stocks of morphine to be held. Planned rollout across Hampshire in May 2014. Service Level Agreement for the direct supply of morphine to Paramedics and BASICS doctors in Hampshire delayed as clarification of Home Office Licencing required. E-learning for the safe and secure management of morphine to be developed. Area Managers reminded of their responsibility to implement Medicines Management Standards and polices. E-learning package for the safe administration of medicines to be developed. Continue to formally review medicines errors each quarter. One medicine error reflection a month to be shared with Team Leaders. 11. Service level agreements The Trust must review the medicines related issues in its service level agreements with other health care providers Contract with private ambulances updated. 13

Controlled Drug Issues Summary of declaration of concerns to NHS England Appendix 2 Concern Ambulance Services fall outside current legislative framework To improve security of NHS Paramedic stock of morphine Berkshire 11Oct12: Missing ampoule of morphine on CR132. Ampoule no. 6596. 27Mar13: Two diazepam ampoules 10mg unaccounted for in Ascot races bag. Stored at Bracknell station. Balance correct on 16Feb13. 19Oct13: Morphine 10mg ampoule unaccounted for on Newbury vehicle. 02Dec13: Vehicle morphine 10mg ampoules x 10 reported as lost from Bracknell safe. 05Dec13: Bracknell morphine management audit identified stock management and recording issues requiring action. 13 Feb 14: Newbury: Oral morphine 30mg administered to patient over 30minutes. Guidelines limit dose to 20mg in 60 minutes 24 Feb14Reading: Morphine 10mg ampoules x 4 missing for vehicle stock stored in station safe. Action taken Proposal to resolve possession of CDs by Ambulance Services in Summer 2013 Vehicle safes have been fitted. Rolled out in Milton Keynes, Buckinghamshire, Oxfordshire and Berkshire (April 2013). Vehicle was in Oxfordshire and Berkshire. Ongoing investigation but ampoule not found. Awaiting final report (Closed report not received) Padlock fitted to cupboard. Key kept in team leader s office and with Make Ready. Awaiting full report (Closed report not received) Unable to locate. Closed Found on vehicle on 19Dec13. Closed. Closed Process reminder issued to staff Reflection received. Paramedic misread guidelines. Closed Feedback sent to guideline authors (AACE) Following up Buckinghamshire 10Mar13: Morphine ampoule discovered missing on vehicle NA510. Hampshire Regular discrepancies reported and resolved. Mainly a result of incomplete completion of paperwork at change of shift and not recording swapping of boxes at hospitals. 17Jul13: Morphine box 573 at Lymington has one morphine 10mg ampoule missing. 21Jul13: Morphine box 645 at Nursling short of one ampoule. 29Dec13: ECP stock check found 2 x diazepam 2mg (6tablets) missing. All crews spoken to for period 8 10March and all PRFs available checked. Assumed morphine ampoule dropped out. Identified two paramedics had incomplete process in place. Awaiting paramedics names. Closed. On going audit and reminders to staff. 08Aug13: Use identified. Awaiting closure and final report. 05Aug13: Use of ampoule identified and paramedic has written a statement. Closed Not found. Process reminder sent to staff. 14

Milton Keynes 16May13. Air ambulance attended patient. Morphine 10mg in 10ml drawn up and 3.5mg administered. Balance could not be found on departure from scene, but unable to search as house locked up. 29Jun13. Three medicines modules, which contain oral morphine, codeine and diazepam preparations have gone missing from vehicles at Milton Keynes (4 th on 30June, reported 0July13) 13Sep13: Morphine 10mg ampoule discovered missing during car shift. 17May13. Patients relatives asked to check garden and scene. Syringe found, and Milton Keynes team member recovered and destroyed. Closed 17May13. Investigation completed and sent to Hertfordshire and South Midlands AO. Blue modules probably taken by a member of public due to ambulances not being locked. Closed 27Aug13 Unable to locate. Previous issue with same paramedic, so morphine use for 12 months reviewed. No further action required. Closed Oxfordshire 23Jan13 Routine audit identified ampoule of morphine 10mg missing at Kidlington correct on 23May12. 07Mar13 One ampoule morphine 10mg discrepancy on NE401. Check correct on 03Mar13. 22Apr13. One ampoule morphine 10mg discrepancy identified late in shift. 19Sep13: Kidlington Vehicle safe unlocked and one morphine 10mg ampoule missing 24Nov13: Adderbury: 4 morphine 10mg ampoules broken. 06 Mar 14: Didcot: vehicle with morphine 10mg ampoule missing. Safe electronic audit trail inactive. Vehicle had moved across Oxfordshire and Buckinghamshire. Ongoing investigation found regular stock checks had missed page with this ampoule and reason for discrepancy not found.. Closed Ongoing investigation could not identify reason for discrepancy in discrete time frame. Poor handover process identified, and staff reminder issued. Closed 31 March 2013. Investigated. Paramedic had not followed handover process, and therefore discrepancy not identified earlier. Ampoule accounted for. Closed 30April13. Morphine use identified. One reflection received. Awaiting second reflection. Witnessed accident. No further action. Closed 29Nov13. Following up 15

Objective Strategy, risk and governance Executive level medicines policy group oversees medication safety and policy development Management of medicines is underpinned by an overarching medicines policy Oversight and control of clinical risks and costs associated with medicines Trust Board and senior management actively involved in medicines optimisation Safe use of medicines South Central Ambulance Medicines Management Programme 2014/2015 Actions required Prescribing policy required Appendix 3 Make medicines policy available to staff at induction, and audit compliance with policy; Develop a robust process to manage clinical risk and costs associated with medicines; Improve upward information to Board members about medicines use. Medicine errors and harm from medicines are measured and lessons learned and routinely embedded in police and practice Policies and procedures for the safe use of medicines are in place Off label medicines are used safely Circulate anonymised medicines error reflections once a month to team leaders and educators. so that learning can be shared with clinical teams; Implement e-learning for ambulance PGD medicines (Codeine, paracetamol intravenous and tranexamic acid); Implement patient charging for supply of PGD medicines; Implement step 2 of the training for the midazolam and ketamine PGDs; Audit standards of medicines management at air ambulances; Review and audit private ambulances adherence to Trusts medicines management specification; Formalise a policy for the safe use of off-label medicines 16

Objective Effective choice of medicines The patient experience Policy for the administration of a patient s own medicines Policy for the patient contact centre to triage and enable patients to administer their own medicines Patients receive the medicines they need Handover of care to enable medicines reconciliation to take place Environment for medicines optimisation Controlled Drugs are managed safely and effectively Workforce for medicines optimisation Work force planning to support delivery of medicines optimisation Medicines are prepared and administered by competent staff Training and development include medicines optimisation Actions required Telephone support for the administration of palliative care medicines; All Clinical Advisors require medicines information training; Develop and audit a policy for the Clinical Support Desks to triage and enable patients to take their own medicines; Explore the feedback of medicines use information to area managers; Green Bag Awareness campaign. Implement Trust policy for the safe management of morphine across Hampshire; Agree Service Level Agreement for the direct supply of morphine to Paramedics and BASICS doctors in Hampshire (subject to Home Office Licensing); Develop e-learning on the safe and secure management of morphine. Pharmacist advice to Workforce Board to highlight mandatory and patient safety medicines education requirements. Strategy for the development of non-medical prescribers; Develop e-learning package for the safe administration of medicines; Medicines optimisation should be developed as part of mandatory training for all clinical staff. Assess Area Managers medicines related training needs. 17

18 Annual Medicines Management Report 2013/2014