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Reducing medication discrepancies in elderly patients

Older patients are more susceptible to harm from polypharmacy and transfer between care settings can result in medication discrepancies. To address this issue Birmingham South Central Clinical Commissioning Group (CCG), in partnership with NHS Midlands and Lancashire Commissioning Support Unit, conducted a pilot project, where prescribing support via a pharmacist and pharmacy technician were offered to GPs through conducting post-discharge medication reviews in patients who were aged over 75 years.

A total of 30 GP practices participated in this pilot project. A designated member of the practice administration team referred the patient via a secure NHS email. The patient would still receive the usual post discharge review with the GP. Remote login to participating surgeries was obtained. All interventions were documented in the patient’s electronic notes.

All patients referred to the team received a clinical pharmacist medication review. This involved reviewing the patient’s medical notes, checking relevant clinical investigations, reviewing the prescription for interactions, and issues with polypharmacy. Depending on the level of intervention required, the patient would be contacted for a telephone consultation, consultation in the surgery or home visit (for housebound patients).

After eight months, 467 patients had been reviewed, with 521 interventions made. These include adverse drug reaction, compliance issues, queries with preadmission medicines and drug formulation issues.

Most queries arose from preadmission medications, which suggested that recent hospital admission should not be the only criterion for pharmacist referral. The team addressed preadmission queries with an emphasis on reducing polypharmacy in agreement of the patient, while evaluating the risks and benefits of continued treatment.

Medication review also highlighted instances of drug stockpiling and waste of medicines. This was resolved on an individual patient basis and future work will feed into a CCG-wide repeat prescribing project.

It was found that a large amount of GP time is spent resolving medicine queries. The pharmacy team resolved these issues for patients referred to the project by liaising with community pharmacists, hospital pharmacists, hospital consultants, junior doctors, community nurses and care homes.

Interventions involving compliance, concordance and formulation utilised the pharmacist’s unique skills. There were 100 compliance issues identified and many patients did not take their medicines as prescribed.

There is considerable scope for clinical pharmacy in general practice. All patients in this study received a clinical pharmacy review in addition to the GP review, yet medication issues were still identified. Since most queries arose from preadmission medicines this may support the extension of this role. The project is planned for 12 months and further findings will be shared at the end of this period.

Karamjit Khangura

Medicines optimisation pharmacist

Lilliana Alani

Medicines optimisation pharmacy technician

NHS Midlands and Lancashire Commissioning Support Unit

Birmingham South Central Clinical Commissioning Group

Citation: Clinical Pharmacist DOI: 10.1211/CP.2016.20201102

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