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Issue 39
Issue 1
June 2016
30 September 2010
Welcome to the March issue of
Featured in this issue:



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Learning from medication incidents.
Drugs and Therapeutics Group Update.
Significant changes in the RT policy.
Effects of bariatric surgery on drug
absorption.
 New guidance on using multidrug blister
packs.

The Pharmacy Team has pulled together all the electronic versions
of medication related documents

including patient information leaflets and prescribing guidance, into one area of the Trust’s website
www.sussexpartnership.nhs.uk/gps/med-info. Please have a look at the wide range of medication related
documents now available.
The Drugs &
Therapeutics
Newsletter
Report and Learn
Lesson 1
An incident has been reported of two patients having medicines administered covertly without full
approval of the MDT in line with Trust guidance. Administering medicines covertly by disguising
medicines in food and drink cannot be encouraged as it exposes patients to risk. It is however
recognised that in exceptional circumstances, covert administration may be justified in the best interests
of a patient. It is vital that all steps are taken to avoid covert administration but if it is being considered as
a ‘best interest’ decision in patients who lack capacity the guidance in chapter 38 of the Trust’s
Medicines Code must be followed and the form at the link below completed:
http://www.sussexpartnership.nhs.uk/node/1593/attachment
Lesson 2
A couple of incidents have come to light that were compounded by there being no record of the patients’
FP10 (community) prescriptions being recorded on Carenotes. The patients’ GPs had also not been
informed that the medication had been prescribed. It is vital that whenever a prescription is written for a
patient a record of the prescription must be put in to Carenotes along with information on why it was
prescribed and any future plans for stopping or continuing with the medication. This information must
also be communicated to the patient’s GP. One of the cases resulted in a coroner criticizing the Trust for
the quality of the communication between the specialist and the patient’s GP. See the GP good
communication checklist at the link below:
http://www.sussexpartnership.nhs.uk/node/1486/attachment
Lesson 3
A patient requested Oxynorm® (oxycodone) for pain on one of our wards, which was prescribed PRN as
a 10mg dose. A dose was administered, but the wrong dose was measured out. Instead of 1ml (10mg)
being given a dose of 10ml was administered (100mg) in error.
Contd…
If you require this document in an alternative format, i.e. easy read, large
text, audio, Braille or a community language please contact the Pharmacy
Team on 01243 623349 (Text Relay calls welcome)
Page 1 of 8
Lesson 3 (continued)
The nurse administering the dose did not realise at the time, but later noted that the patient was 'off
colour', wobbly and shaking even though the patient denied feeling ill. Physical observations were taken
at around 17.00 hours with BP 142/90, pulse 90, oxygen saturation 92% dropping to 85%, respiratory
rate 15 and blood glucose 7.2mmol. The patient was noted to have pin prick pupils and the staff nurse
realised that there had been an error in the administrations of the medication. The on call doctor was
contacted and attended immediately. Further observations were taken and three doses of naloxone were
administered in just under an hour before the patient was transferred to the local A & E for monitoring
overnight.
On investigation it was discovered that the second person checking the administration had only checked
that the dose measured out was correct against the quantity booked out of the CD register and had not
seen the drug chart or witnessed the administration. This incident could have been much more serious
had the overdose been administered late in the evening just before the patient went to bed, when the
impact of the overdose on her would have been less likely to be noticed. There are significant risks
associated with opiate overdoses and it is crucial, not just for security reasons, that two people properly
check the whole process when CDs are administered and if the patient is competent, ask them what dose
they are expecting, as an additional check.
A summary of medication related incidents reported is published monthly in the Trust’s Report &
Learn Bulletin. This is only available to staff with a Sussex Partnership e-mail address on the
Trust’s intranet (SUSI) at the link: http://susie.sussexpartnership.nhs.uk/myorganisation/directorates/nursing-and-quality/governance/patient-safety
Updated Rapid Tranquilization (RT) policy
The RT policy has been updated following the publication of NICE guidance: NG10: Violence and
aggression: short-term management in mental health, health and community settings. The link to view
the full NICE guidance is: www.nice.org.uk/guidance/ng10/resources/violence-and-aggression-shorttermmanagement-in-mental-health-health-and-community-settings-1837264712389
There are a number of important changes to note:
 RT now only refers to the use of medication by the parental. It should be used only if
administering oral medication is not possible or appropriate or urgent sedation with medication is
needed.
 Based on the evidence the two management strategies are:o An IM benzodiazepine (lorazepam) used alone
or
o The combination of IM haloperidol plus an IM antihistamine (promethazine).
 NICE guideline NG10 does not include the use of olanzapine IM injection as there is no UK
product available, having been withdrawn from the market. EU-licensed products are available
and so it has been included in the Trust’s policy as an option.
 When prescribing medication for use in RT, write the initial prescription as a single dose and do
not repeat until the effect or the initial dose has been reviewed.
 Where possible, (and where it is safe to do so), temperature, pulse, respiration rate and blood
pressure, level of hydration and level of consciousness should be recorded at least every 30
minutes for a minimum of 2 hours or until no further concerns about physical health following the
parenteral administration of any drug. Monitor every 15 minutes if the patient has risks factors as
stated in the policy.
 If the patient refuses or declines monitoring, ‘R’ for refusal should be endorsed on the chart and as
a minimum respiration rate should be monitored and recorded every 30 minutes (or 15 minutes for
at risk patients). This would include patients held in seclusion.
 For the first time a learning disability section and flow chart is included in the policy.
 The RT online training module will be updated to reflect these changes.
The new policy will not be adopted until the new rotation of junior doctors starts on 1st August 2016. The
new policy (from 1st August) and the current policy (until 31st July) are at the link:
www.sussexpartnership.nhs.uk/node/1523/attachment
Page 2 of 8
Phenelzine leaflet for GPs
Though rarely used these days, the non-reversible monoamine-oxidase inhibitor (MAOI) phenelzine still
has a place in therapy to treat resistant depression. Because many younger GPs will not be used to
prescribing this antidepressant it has been agreed that in future, if initiated by secondary care, the dose
should be stabilized and the benefits seen before considering asking the GP to prescribe it. Even then
the GP may feel they do not have the clinical skills to take on the prescribing. To help educate GPs on
this unusual drug a leaflet has been developed with the help of one of the Brighton Area Prescribing
Committee. A copy must be sent to any GP when first asking them to take over responsibility for
prescribing. It is hoped it will reduce the number of GPs unwilling to take over the prescribing long-term.
The leaflet can be found at the link:
http://www.sussexpartnership.nhs.uk/node/3345/attachment
Prescribers are reminded that the other two non-reversible MAOIs, namely tranylcyromine and
isocarboxazid are no longer on the Trust’s Formulary due to their extremely high cost. Tranylcypromine
costs £3,198 pa for a 10mg daily dose and isocarboxazid £2,340 pa for a 20mg daily dose. This
compares to £82 pa for a phenelzine 15mg daily dose.
Recent notifications of additional side-effects
Lamotrigine: Alopecia and drug reaction with eosinophilia and systemic symptoms (DRESS) have been
added as potential adverse drug reactions to the summary of product characteristics.
Olanzapine: The FDA is now highlighting that drug reaction with eosinophilia and systemic symptoms
(DRESS) has been associated with olanzapine therapy. If DRESS is suspected olanzapine therapy
should be stopped immediately.
Aripiprazole: Although pathological gambling is listed as a reported side effect in the current aripiprazole
SPCs and patient information leaflets, this description does not entirely reflect the nature of the impulsecontrol risk that are identified. In addition, the FDA has become aware of other compulsive behaviours
associated with aripiprazole, such as compulsive eating, shopping, and sexual actions. These compulsive
behaviours can affect anyone who is taking the medicine. As a result, the FDA is adding new warnings
about all of these to the drug labels and the patient Medication Guides for all aripiprazole products.
Patients and carers should be alerted to look for uncontrollable and excessive urges and behaviours
while taking aripiprazole. It is important patients and carers talk with a healthcare professional as soon as
possible if they or a family member experiences any of these uncontrollable urges, in order to prevent or
limit possible harm. Patients should be warned not to suddenly stop taking their aripiprazole medicine
without first talking to their healthcare professional.
Serotonin syndrome leaflets for patients, carers and parents
The two Trust leaflets on serotonin syndrome, one for parents and the other for adults and older
adolescents, have recently been updated to include the substance 5-hydroxytryptophan (5HTP). These
can be found at the two links below:
www.sussexpartnership.nhs.uk/node/3423/attachment
www.sussexpartnership.nhs.uk/node/2711/attachment
Drugs & Therapeutics Group Update
1. New consolidated guidance on managing prolonged epileptic seizures has been approved
replacing a number of older guidelines. This new guidance is available at the link:
www.sussexpartnership.nhs.uk/node/3388/attachment
Page 3 of 8
2. An updated Rapid Tranquillization Policy has been finalised following further comments at the
Drugs & Therapeutics Group meeting. It has been decided to launch it on the 1st August to coincide
with arrival of the new junior doctors (see longer article on the main changes). but. At present it links
to the current guidance but it will change for the 1st August:
www.sussexpartnership.nhs.uk/node/1523/attachment
3. An updated Vision and Strategy for Medicines Optimization was approved and is available at the
link: www.sussexpartnership.nhs.uk/node/1433/attachment. Since the last version was published in
2014 significant progress has been made in several areas:

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All admission wards now have dedicated medicine optimization pharmacy technicians. In
February 2014 some of the wards were not covered in East Sussex.
Four whole time equivalent pharmacists are now employed to work with the adult community
mental health teams.
Pharmacy support to the Learning Disability Service has doubled, but is still limited.
A Medicines Safety Officer has been appointed.
SUSI has been reviewed to make links to the medication related material on the Trust’s
external website more obvious.
The one notable area where no progress has been made is in the introduction of an electronic
prescribing and medicine administration system.
4. It was confirmed that F1 junior doctors are not authorised to prescribe oral anti-cancer medicines
(even if prescribed for other conditions, e.g. methotrexate for rheumatoid arthritis, on FP10
prescriptions, drug charts or discharge prescriptions. They are also not authorised to prescribe
Schedule 2 and 3 controlled drugs on FP10s or discharge prescriptions, but can write them on
inpatient drug charts if supervised by a senior colleague.
Bariatric surgery and its impact on drug absorption
It is important to remember drug dosage and regimens are developed in trials involving participants with
‘normal’ gastrointestinal anatomy. Therefore bariatric patients may exhibit altered responses to standard
medications and doses. Please bear this in mind if treating a patient who has had bariatric surgery.
The table of psychotropic medication with specific advice following bariatric surgery was taken from an
article in Clinical Pharmacy vol 8, No3, March 2016.
Medication
Amitriptyline
Evidence for altered absorption
Possibly reduced (in vitro)
Citalopram
Fluoxetine
Lamotragine
Lithium carbonate
Olanzapine
No significant change/possibly
reduced
Reduced (in vitro)
Possibly reduced
Increased
Reduced
Paroxetine
Sertraline
Reduced (in vitro)
Reduced (in vitro)
Possible action
Monitor levels closely.
Lipophillic drug
Close psychiatric monitoring
Close psychiatric monitoring
Monitor closely
Close psychiatric monitoring
Close psychiatric monitoring.
Monitor levels regularly
Close psychiatric monitoring
Close psychiatric monitoring
Administering medicines on wards from multidrug blister packs
There are occasions when patients are admitted using multidrug blister packs that have several different
doses in one blister compartment of their compliance aid. Some compliance aids have a different pack
for each different drug, which makes identification easy. Until now the Trust has not authorized nurses to
ever administer medicines from these multidrug blister packs. There are occasions however, when had
there been a clear process to follow, patients written up on admission for non-stock drugs could have
Page 4 of 8
had a few doses safely administered from their multidrug blister pack without the need for the patient to
miss a dose or time being wasted getting an FP10 prescription written and then dispensed from a
community pharmacy.
There is now a new guideline on the Trust’s website that has a flowchart to work through so nurses can
be confident that if the multidrug blister pack meets certain criteria and they are able to correctly identify
the dose against the pharmacy description of the tablet/capsule, they can administer it safely. The new
guidelines can be found at the link below:
www.sussexpartnership.nhs.uk/node/3434/attachment
Community long-acting antipsychotic injection (LAAI) prescription and administration chart
Below is a link to another update to the community LAAI prescription and administration chart. With the
recent employment of the new community adult mental health pharmacists, they have picked up
comments from clinicians using them and have made some suggestions to improve it. The two main
changes are:



Renaming the old ‘Pharmacy’ box as ‘Comments’ so anyone can use the space.
Adding a ‘Pharmacy screen’ box, as in future the new community based pharmacists will be
screening the prescriptions in the same way they would have screen a similar prescription written
on a ward drug chart.
Updating the notes at the bottom of the first page to reflect the introduction of Carenotes and the
move to paperless patient records.
There are a few other minor changes as well. If you have any concerns with the new chart, please speak
to your local pharmacist. A copy of the new form can be seen at the link below, but the new version has
already been distributed via clinic co-ordinators and the pharmacy team.
www.sussexpartnership.nhs.uk/node/1605/attachment
On-line training materials on antipsychotics, benzodiazepines and SSRIs
The Medicines and Healthcare Products Regulatory Authority (MHRA) has developed several learning
modules for clinical practitioners. These are self-directed learning packages, which are approved for
continuing professional education (CPD). They outline the key risks of prescribing these widely
prescribed classes of medicines. For the different adverse effects, the module outlines the main features
of the adverse effect:
• Factors that increase the risk
• How the risk can be reduced
• Specific treatment for the adverse effect
Antipsychotics learning module (up to 3.5 CPD credits – estimated time 3.5 hours)
Benzodiazepine module (up to 2.5 CPD credits – estimated time 2.5 hours)
SSRI learning module (up to 2.5 CPD credits – estimated time 2.5 hours)
These and other medicine related modules can be accessed via:
www.gov.uk/government/publications/e-learning-modules-medicines-and-medical-devices/e-learningmodules-medicines-and-medical-devices
Page 5 of 8
Sample FP10 Drug Costs as of 1st June 2016
Oral/Dermal Preparations
Name of drug
Antipsychotics
Amisulpride
Aripiprazole
Clozapine
Olanzapine
Olanzapine
Perphenazine
Quetiapine
Quetiapine
Risperidone
Risperidone
Sulpiride
Dose
(mg)
Daily
dose(mg) Formulation
Cost per
day
Cost per 28
days
Comment
400
15
100
10
10
4
300
300
3
3
400
800
15
450
10
10
12
600
600
3
3
800
tablets
tablets
tablets
tablets
orodispersible
tablets
XL tablets
IR tablets
orodispersible
tablets
tablets
£1.17
£0.20
£1.93
£0.04
£0.10
£1.03
£5.67
£0.11
£1.20
£0.03
£1.25
25
20
60
10
30
50
25
20
60
20
30
100
tablets
tablets
capsules
tablets
tablets
tablets
£1.07
£0.03
£0.34
£0.08
£0.04
£0.09
£30.00
£0.82
£9.43
£2.34
£1.21
£2.56
Mood stabilizers
Sodium valproate
Valproate semisodium
500
500
1500
1500
c/r tablets
tablets
£0.24
£0.87
£6.70
£24.44
Anxiolytics
Clonazepam
Lorazepam
Pregabalin
0.5
1
150
1.5
3
300
tablets
tablets
capsules
£0.75
£0.22
£2.30
£20.96
£6.06
£64.40
Dementia treatments
Donepezil
Galantamine
Memantine
Rivastigmine
Rivastigmine
10
24
20
6
9.5
10
24
20
12
9.5
tablets
MR capsules
tablets
capsules
patches
£0.05
£2.85
£0.05
£0.57
£0.49
£1.45 First-line cholinesterase inhibitor
£79.80
£1.52
£15.89
£13.81
Antidepressants
Agomelatine
Citalopram
Duloxetine
Escitalopram
Mirtazapine
Sertraline
£32.87
£5.71
£54.30
£1.13
£2.81 Only use if essential
£28.84
£158.66 Only use if essential beyond initation
£2.99
£33.50 Only use if essential
£0.78
£35.10
TDS costs 50% more than BD dosing
Long acting antipsychotic injections
Dose
Name of drug
(mg)
Antipsychotics
Aripiprazole
400
Risperidone
25
Risperidone
37.5
Risperidone
50
Paliperidone
50
Paliperidone
75
Paliperidone
100
Flupentixol Decanoate
80
Haloperidol Decanoate
200
Zuclopenthixol Decanoate 500
Monthly
dose(mg) Formulation
400
50
75
100
50
75
100
160
200
1000
LAI
LAI
LAI
LAI
LAI
LAI
LAI
LAI
LAI
LAI
Cost per
dose
Cost per 28
days
Comments
£213.30
£79.69
£111.32
£142.76
£183.92
£244.90
£314.07
£6.25
£10.10
£7.44
Prices obtained from Drug Tarrif - June 2016 or BNF 70 - September 2015
Page 6 of 8
£199.08
£159.38
£222.64
£285.52
£171.66
£228.59
£293.14
£12.50
£10.10
£14.88
*28 day equiv. price if given 12xyr
*28 day equiv. price if given 12xyr
*28 day equiv. price if given 12xyr
*28 day equiv. price if given 12xyr
Controlled Drugs Accountable Officer
Following one of the recommendations from the Shipman report, the Government has made it a legal
responsibility that every NHS Trust has a Controlled Drugs Accountable Officer (CDAO) to ensure the
safe handling and use of controlled drugs (CDs) in the Trust. This role is performed by Ray Lyon, Chief
Pharmacist – Strategy. Many other organizations are also obliged to have their own CDAO including
hospices and private hospitals. As part of his role the CDAO monitors all medication incidents reported
that involve a CD. Occasionally the CDAO may have to personally investigate an incident and provide
advice. Every quarter the CDAO is obliged to send in a detailed summary of any significant CD
occurrence that has taken place within their organization in our case to the CDAOs for the NHS England
Kent, Surrey & Sussex and Wessex localities, as we provide services in Hampshire, Kent and Sussex. In
addition the total number of CD incidents completed is summarized and broken down into categories.
If any member of staff has concerns about the handling, prescribing or diversion of a controlled drug they
are strongly encouraged to confidentially share their concerns with their line manager or directly with Ray
Lyon. His email is address is [email protected] or he can be contacted on 07833
527412.
Risks of incorrect dosing of oral anti-cancer medicines
All healthcare staff involved in the use of oral anti-cancer medicines must be aware of the potentially fatal
outcomes if incorrect doses of these medicines are prescribed or administered. Oral anti-cancer
medicines are increasingly being used in hospitals and in the community. Risks are increased if nonspecialist practitioners prescribe, dispense or administer these oral medicines and bypass the normal
safeguards used for injectable anti-cancer medicines. Between November 2003 and July 2007 three
deaths and a further 400 patient safety incidents concerning oral anti-cancer medicines were reported.
Half of these reports concern the wrong dosage, frequency, quantity or duration of oral anti-cancer
medicines.
Our doctors, nurses and pharmacists need to be aware that the prescribing, dispensing and administering
of oral anti-cancer medicines should be carried out and monitored to the same standard as when dealing
with injected cancer therapy. Though the use of oral cancer drugs in mental health units is minimal, the
risks when prescribed are high and usage is likely to increase as more oral cancer drugs become
available. National guidance requires that:





Healthcare organizations prepare local policies and procedures that describe the safe use of
these oral medicines - the Trust’s Medicines Code reflects this advice.
Treatment should only be initiated by a cancer specialist.
All oral anti-cancer medicines should be prescribed only in the context of a written protocol and
treatment plan including guidance on monitoring and the treatment of toxicity – copies of this will
be available from the hospital initiating the treatment if the service user fails to bring a copy of their
treatment plan in with them.
FI doctors are not allowed to prescribe oral anti-cancer drugs.
Staff dispensing oral anti-cancer medicines should be able to confirm that the prescribed dose is
appropriate for the patient, and that the patient is aware of the required monitoring arrangements,
by having access to information in the written protocol and treatment plan from the hospital where
treatment is initiated and advice from a pharmacist with experience in cancer treatment in that
hospital.
Full use should also be made of the initiating hospital’s cancer specialist team to provide information for
our staff, patients and carers to ensure the safe use of oral anti-cancer medicines when patients on them
are admitted.
Page 7 of 8
Reducing Errors with Opioid Medicines
The National Patient Safety Agency (NPSA) raised concerns several years ago about opioid medicines,
which have an invaluable role in the treatment of acute and chronic pain. However, there are risks if
members of the healthcare team who prescribe, dispense or administer opioid medicines have insufficient
knowledge of dosage and the requirements of the patient concerned. Every member of the team has
responsibility to check that the intended dose is safe for the individual patient. Incidents have been
reported to the National Reporting and Learning System (NRLS) concerning patients receiving unsafe
doses of opioid medicines, where members of the clinical team have not checked the current opioid dose
and given an incorrect dose or formulation (see one of this edition’s Report and Learn lessons.)
There are a wide variety of opioid medicines and this may result in products being used that are
unfamiliar to practitioners. In addition, patients response to opioid medicines varies widely and is partly
dependant on previous doses received. The term ‘opioid medicines’ refers to the following medicines,
including commercial brands:
Buprenorphine
Codeine
Diamorphine
Dipipanone
l
Fentanyl
Hydromorphone
Meptazinol
Methadone
Morphine
Oxycodone
Papaveretum
Pethidine
Pease do not hesitate to contact either Ray Lyon or Jed Hewitt if you require further information on any of
the topics covered in this newsletter or you have any suggestions to improve it.
Jed Hewitt, Chief Pharmacist –
Governance and Professional Practice
[email protected]
Ray Lyon, Chief Pharmacist - Strategy
[email protected]
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