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Switching between monitored dosage systems and patient pack dispensing

Many will be supportive of Boots’s decision to change its method of dispensing for care home residents from monitored dosage system (MDS) to patient pack dispensing (PPD). However, this U-turn prompted me to reflect on my original recommendation to care homes in Derbyshire, during the 1980s, for care homes to switch from PPD to MDS.

As social services pharmacist for Derbyshire Area Health Authority and Derbyshire Social Services Department, I was astonished to discover that care home staff were removing solid dosage forms from containers supplied by pharmacies and administering them from make-shift containers (such as egg and ice trays). Staff were inadvertently introducing an additional step and potential for error to the process.

I recommended that the administration of each dose should be documented, and that medicines should be administered directly from the containers supplied by pharmacies. Research conducted as part of my PhD proved that solid dosage form administration errors were fewer and time taken to complete a medicine round was reduced when using MDS, compared with re-dispensing and with administration direct from traditional containers.

Practicability of safe medicine administration in the context of unavoidable concurrence of social care tasks (such as answering the phone or attending to a fallen resident) was also enhanced by using MDS. Partly based on this research, Boots offered MDS to UK care homes at no extra cost in exchange for receiving residents’ prescriptions. 

A senior social care manager at one of these care homes once told me that MDS was a “godsend”, so I agree with Lelly Oboh when she says that the switch back to PPD could result in outcry. There is also a risk that the switch may mean some homes revert to the dangerous practice of re-dispensing.

Guidance from the National Institute for Health and Care Excellence and the Royal Pharmaceutical Society may not sufficiently recognise care home culture, which primarily embraces personal care as opposed to healthcare. Medicines administration in this environment is complex, so care home staff need much more than an online self-study programme on PPD. Personal care in care homes is very demanding and undertaken with minimal staffing resources; for example, one staff member per medicine round. Care workers deserve support from pharmacies that are willing to continue providing MDS.

I don’t think MDS should necessarily become the default system — there will be occasions where care homes are able to safely administer medicines using PPD. Pharmacists should take the lead in reviewing (with care home heads) the type of dispensing system and support that would best help staff to provide excellent personal care. Where MDS is provided, resources should be allocated, through health or social care budgets, to ensure pharmacies are remunerated for the support they provide.

 

Peter Rivers, retired academic and pharmacist, Derbyshire

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2019.20206259

Readers' comments (3)

  • Thanks for sharing that Peter... as a previous nursing home nurse (the hardest job ever- med rounds for 40+ residents) and District Nurse for many years, have witnessed this complex and potential risky environment. Understand why it seems an over reliance, but each place would need to be assessed for safety, one aspect of which is how supported they are by other professionals such as pharmacists or DNs.

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  • Medication administration is a high risk task.
    It should ideally be undertaken by registered nursing staff using original packs.

    In many situations this high risk task is delegated to non registered care staff. Many may only have a few days training in medication administration. They may be unaware of monitoring requirements, side effects etc.

    The issue is really:
    Does society value those vulnerable populations living in care homes, those with intellectual disabilities etc. enough to ensure that they have the highest standard of care?

    Do management and /or policy makers etc. see medication administration as a high risk task and one that should be undertaken by adequately trained and registered nursing staff?

    Do vulnerable people living in care homes etc. not deserve the highest standard of care?

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  • Thank you, Jill and Bernadette, for your thoughts. Thinking about Bernadette's view ----- that only professionals fully trained in medication administration processes (i.e. registrered nurses) should be allowed administer medication to this vulnerable population. Well, yes, you are talking about an 'ideal' world that unfortunately does not exist in many care homes where social care is provided as a separate service to that part of the care home where nursing care is provided. In the days of old (the 80s) care homes were either providing nursing care OR social care. Nowadays, most homes offer both types of care. There is tremendous overlap of course, between the needs of the residents who receive social care, on the one hand, and nursing care on the other. However, the current situation is that that, where social care is provided, the staff will be trained in social care and will not be registered nurses. The cost of the care is reflected in the different 'level' of staffing. So, I would say that, although it would be desirable for all staff to be equivalently trainined in medication procedures, the current reality (and I can't see this changing in the immediately future, if ever) is that social carers deserve support from health professionals such as pharmacists. I don't think we can continue to shift the 'blame' as it were, onto the caring sector. As pharmacists we should recognise the current situation for social care staff and we should support them. However, funding for pharmacists to provide this support has so far been lacking, and this is something that really does need to be addressed.

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