Prescribing and administration for medical inpatients with parkinsonism

Background

PD patients in hospital often face problems with prescription and administration of medications. Missed or omitted doses lead to increased rates of complications, longer length of stay and increased mortality. A National Patient Safety Agency report in 2010 highlighted problems with missed/late administration of drugs, and specifically cited PD as a significant area of problems¹. The ‘Get It on Time’ campaign encouraged local audit and action to improve prescription and administration.

Methods

Northwick Park Hospital in London is a large, busy hospital. Medical take lists were screened for two months; eligible patients were all patients with parkinsonian disorders. Data was collected after admission on initial prescription of usual drugs and at the end of admission on administration. If feasible, a questionnaire was administered to the patient asking about their perception of problems with drug administration. The drawbacks of this approach were that we missed some patients as this methodology only covered medical patients.

Results

• 36 eligible patients, complete data on 28
  • 35 PD (+/- PDD)
  • 1 PSP
• 71 prescriptions
  • 10 (14%) incorrect dose or formulation
  • 23 (32%) incorrect time(s)
  • Average 31 hour delay to correction (range 2-96)
  • Almost all corrections made by pharmacists
• Administration
  • Total 1,494 doses administered
  • 187 doses (12.5%) omitted
  • Excluding one dying patient, 79 doses (5.3%) omitted
  • 46 (3%) doses given late
• 9 patients made NBM during admission
  • 7 had appropriate strategy implemented
• 17 patients completed survey
  • None reported frequent problems with getting their PD drugs
  • 6 (35%) reported occasional problems with getting their PD drugs
  • 4 (24%) reported problems with their PD as a result of problems with their drugs
• 8 out of 29 patients were definitely or probably suitable for self-administration but several suggested they were reluctant to do this while in hospital
  • “I’d rather leave it to the professionals”

Conclusions & plans

We identified significant errors in prescribing, resulting in omitted and incorrectly timed doses (sometimes for several days). There were also some problems with administration. The majority of patients were not suitable for self-administration.

Improvements to the audit include:

• FY1 data collection
• Ask all suitable patients about self-administration
• Record exact problems with formulation/dose prescription
• Match day/time of admission with prescription errors

Plans

• Education session with FY and CMTs
• More info re NBM strategies in pharmacy intranet site
• Emergency drugs cupboard
• Present audit results locally to Elderly Med teams and educate
• Re-audit
  • Assess the impact of missed/omitted doses?

2016 update: We implemented education sessions with junior doctors, and presented to both the elderly medicine dept and the wider general medicine department. A trust guideline has now been developed, available on the intranet site and pharmacy have reviewed their emergency medicine stocks to include most of the medications highlighted. The neurologists have also started a movement disorder ward round on Monday afternoon to trouble shoot the complex patients. The guideline has now been in place for three months – we will re-audit in a few months’ time.

Reference

1. http://www.nrls.npsa.nhs.uk/Ea...