introduction to medicines, poisons and pharmacy calls ruth cheema medicines information pharmacist...

Introduction to Medicines, Poisons and Pharmacy Calls

Ruth Cheema

Medicines Information Pharmacist

Trent Medicines Information Service

For Health Advisors, Health Information Staff and Nurse Advisors


Aim

To enable all staff answering Medicines, Poisons and Pharmacy calls to work within role competencies and fulfil them safely, reliably and effectively in this area of care.


Learning Outcomes

1. Have an overview of NHS Direct’s Pharmacy and Medicines Services

2. Have an overview of UK Medicines Information Services, National Poisons Information Service and Community Pharmacy Services

3. Have a baseline knowledge for handling Medicines and Poisons Calls


Session Timetable

NHS Direct’s Pharmacy and Medicines Services Workshop 1 Ethical Dilemmas

Overview of UK Medicines Information Overview on National Poisons Information Service

Break Overview of Community Pharmacy Services Baseline Knowledge for handling Medicines Calls

Workshop 2 What is a Medicine? What Next?


Session Timetable



Break Overview of Community Pharmacy Services Baseline Knowledge for handling Medicines Call



NHS Direct’s Pharmacy and Medicines Services

Why learn about Pharmacy and Medicines?

Research from 2000 showed

6% of all calls to NHSD are for advice about medicines40% of calls include advice about medicines



Medicine Calls may involve

Prescription-only Medicines (POM)

Homeopathic preparations

Pharmacy Medicines (P)

Food supplements and vitamins

General Sales List Medicines (GSL)

Recreational drugs and drugs of abuse

Herbal remedies Steroids in sport



Is there a Policy?

Look inNHS Direct National

Policy for Handling

Medicines Calls NP005



Definition of Medicine Calls

Approved Reference Sources

Principles for Handling Medicines calls

Record keeping and Documentation

(Poisons calls) Quality Assurance

Guidance for specific types of calls

Training and Development

NP005 covers



NP005 Definition of Medicines Any substance or article which is manufactured, sold, supplied, imported or exported for use wholly or mainly in

Treating or preventing disease

Diagnosing disease or status of a physiological condition

Contraception

Inducing anaesthesia

Temporarily or permanently affecting a physiological function in any way



Overview of the roles of different staff in handling medicines calls: role competencies and limitations

Call Handlers/Health Advisors

Information on access to medicines, repeat prescriptions, P4Q calls

Health information staff

Medicines Information when no new or worsening symptoms

Nurse Advisors Medicines advice when new or worsening symptoms present



P4Quick CallP4 Priority Quick Calls on access to pharmacy

services and medicines e.g.

Emergency Hormonal Contraception

Information on missed contraceptive pills

Repeat medication

Access to medicines

do not need to be referred to Health Information.

Details in the Medicines handling Policy NP005



Other NHS Direct PoliciesNP001 – National Guidance for the Management of Frequent Callers

NP002 – National Policy for the Referral of Callers with Mental Health Issues to Mental Health Helplines

NHS Direct FAQs regarding Protecting and Using Patient Information

NHS Direct Child Protection Policy

NHS Direct Adverse Incident Management Policy

NHS Direct Complaints and Feedback Policy

NHS Direct Third Party Calls Policy



Compulsory checks for new/active or recurrent symptoms

“Are you calling about an injury or a new or worsening health

problem?”



Risk Factors in taking medicines calls

Misunderstanding what the caller said

Omitting relevant information sources

Missed symptoms Working outside level of competency

Incomplete background information

Caller doesn’t understand the answer

Incomplete documentation Inaccurate documentation


Session Timetable






Ethical Dilemmas

Medicines calls that may lead to ethical dilemmas Age of caller Third party calls Refusal of another HCP to supply a medicine Caller not wishing to disclose information to Dr Wrong information given to caller by HCP Caller taking a higher dose than prescribed Caller wants information about how to obtain a medicine

that is of dubious worth Caller prescribed two interacting medicines


Ethical Dilemmas

I found a tablet….My G.P. says this…. but I’ve read the other….Does heroin interact with…..?Could my partner’s tablets cause……?


Ethical Dilemmas – General Guidance

All the published information sources that you use are in the public domain.

Instinct: You may have to do what seems right to you.

You do not have to answer everything that you are asked!

Document carefully everything that you do

There are often no “right answers” .Give yourself thinking timeSecond opinion: try to speak to a colleague or to the Medicines Information Centre.Conflicts: try not to get caught up in patient conflicts with other professionals.


Workshop 1 – Ethical Dilemmas

A man asks how long cocaine stays in the body. He used some cocaine at the weekend but is due to have a drug test tomorrow.

What advice would you give?

A woman says she has found some medicines in her son’s room. She reads the labels - lamivudine, zidovudine & saquinavir.

Can you tell her what they are for? Would your answer be different if the call was from his wife?


Session Timetable






Overview of UK Medicines Information

UKMi - supports MI needs of NHS health professionals

>½ million enquiries 2005

16 regional & 260 local centres

Specialist services - pregnancy, breastfeeding, liver disease

Training, websites, QA, drug reviews



Your Medicines Information Service

Your team photo



Staff Pharmacists Pre-registration students Secretarial support

Service to NHS Direct Complex medicines calls MI skills training Quality Assurance National work

9am - 5.00pmYour MI phone

number


Refer to the UKMi Service if You need interpretation of call You have no information or it is unclear It is a complex call Not within your competency

Name, hours and contact details of your Regional MI

Service



Caller taking 3 or more prescription medicines

Dose(s) outside the normal range

Unlicensed use of medicine or use of unlicensed medicine

High risk medicines e.g. aminophylline, carbamazepine, digoxin, lithium, methotrexate, phenytoin, theophylline, warfarin

Medicines in pregnancy or breastfeeding

Complex Calls



Session Timetable NHS Direct’s Pharmacy and Medicines Services

Workshop 1 Ethical Dilemmas Overview of UK Medicines Information Overview on National Poisons Information Service




24 hour, UK wide clinical toxicology service for healthcare professionals

Staffed by Poisons Information Specialists, Nurses, Pharmacists, Physicians

Provide information & advice on diagnosis, treatment and management of poisoning

Overview of National Poisons Information Service



Five poisons centres

Belfast, Cardiff, Birmingham, Edinburgh, Newcastle

One national number 24/7

0870 600 6266



TOXBASE®

Primary Clinical Toxicology database of NPIS

Available to healthcare professionals only

Contains colour-coded NHS Direct advice boxes

Updated daily

Low Toxicity Poster – substances safe if ingested

At NHS Direct used by NAs only


Provides information on toxicity and management of acute poisoning for over 14,000 products – search by brand name or type of product

TOXBASE®


Pharmaceuticals Household & other Commercial Products

Industrial Chemicals Plants

Agricultural Chemicals Snakes

Veterinary Products Insect Bites


Session Timetable






Overview of Community Pharmacy Services


10 facts about Community Pharmacy6 million people visit a community pharmacy every day.

94% population use the local pharmacies at least once a year.

Community pharmacy could manage up to 8% of adult attendances to A&E.80% repeat prescriptions could be handled by community pharmacists, saving 2.7 million hours of GP/practice time.

NHS could save £380 million/year if 1 in 4 people consulted their pharmacist about minor ailments instead of the GP.



10 facts about Community Pharmacy30% PCTs developing schemes to provide patients treatment for minor ailments through pharmacies.

In 2002, the NHS medicines bill was £8 billion, 250% more than in 1990.

In 2002, 712 million prescription items were dispensed, 50% more than 1990.

75% GPs say pharmacists should be able to prescribe certain medicines and offer extended advisory services.

In one study, 66% of patients did not require all prescription items to be dispensed.



Started 1st Apr 2005, monitoring delayed until Oct

Benefits Improve access to community pharmacy Expand range of services provided Make better use of pharmacist skills Help reduce workload pressures on GPs

3 levels of service: Essential, Advanced, Enhanced

New Contract



Dispensing Patient records Compliance support Electronic transfer

of prescriptions

Repeat dispensing Pharmacist

managed repeats

Disposal of unwanted medicines

Health promotion 6 campaigns / year

Signposting

Support for self care

Clinical Governance

Essential services



Optional

Accreditation to provide

Medicines Use Review Long-term conditions Identified by PCT Report to patient and GP

Prescription Intervention Response to specific issue Report to patient and GP

Advanced Services

Accreditation

Pharmacist has passed a competency test

Patient and pharmacist can sit down together

Talk normally without being overheard

Private consultation area



PCTs may commission to meet local need

May implement recognised services or develop own initiatives

Enhanced Services

Suggested Enhanced Services

Minor Ailments

Smoking Cessation

Supervised Administration of

Medicines

Anticoagulant Monitoring

Needle Exchange Schemes

Care Home Support

Emergency Hormonal Contraception Schemes

Medicines Review



Staff in a community pharmacySales assistants Trained to work in shop

but not to sell or advise on medicines

Counter assistants Trained to sell and advise on medicines – supervision by pharmacist

Dispensing technicians Trained to dispense Rx – all checked by pharmacist

Pharmacist Responsible for all sales and Rx of medicines

By law a pharmacy is not a pharmacy if pharmacist not present



Access hours

Monday – Saturday standard ‘shop hours’

OOH system to cover evenings and Sunday by local agreement



Out of Hours (OOH) Provision

Check NHS.uk for details of local arrangements for OOH service

Look on NHS Direct online under Common Health Problems for

Emergency Supply of medicines from a community pharmacy



Emergency Supply by a pharmacist – £ charge to patientPharmacist must interview the person

Immediate need and impractical to obtain a prescriptionPreviously prescribed for the personDose appropriate for the person

Supply up to 5 days except Insulin, ointment, cream, drops, inhaler – smallest pack Oral contraceptive - a full cycle Antibiotic - a full course of treatment

Do not supply a Controlled Drug Except phenobarbitone for epilepsy



NHS Prescription Charges£6.65 for each NHS Prescription

Irrespective of cost to NHS of medicine

Irrespective of quantity

Same drug and form is one charge

Various charges for combination products

Pre-payment certificates – forms from community pharmacies



Aged under 16 Aged 16, 17 or 18 years in full time education. Aged 60 or over. Has a Maternity Exemption certificate. Has a Medical Exemption certificate. Has a War Pension exemption certificate. Has a Prescription Prepayment certificate. Named on a NHS Charge certificate (HC2). Prescribed free of charge oral contraceptives. Gets Income Support or Income Based Jobseekers

Allowance. Entitled to / named on, NHS Tax Credit

Exemption certificate. Partner gets Pension Credit Guarantee Credit.

Exemptions from prescription charge


.


ConfidentialityCode of Ethics – Pharmacist must treat patients with confidentiality

Data Protection Act – Includes paper and computerised patient medication records

Caldicott Principles – Good practice for using patient information in the NHS

Advanced Services – Private consultation area



Patient demographics Medication dispensed

Drug – brand/formulation Strength Quantity Date

Special Notes Counselling given No clic-locks Allergies

Patient Medication Records



NHS Rxs on PMR Private Rxs - in bound book

or on PMR Controlled drugs obtained or

supplied - in bound book

Record Keeping

Checks by

RPSGB inspector

Superintendent Pharmacists

Police



Emergency Hormonal Contraception (EHC)

Pharmacists may

Sell EHC (cost to patient) subject to certain restrictions e.g.age of patient

Supply EHC (free to patient) subject to pharmacist training and according to local guidelines (PGDs)



Existing arrangements - prescriptions for oxygen dispensed at community pharmacy

From 2006 new arrangements in place

Patients will receive oxygen directly from supplier

Oxygen



Session Timetable






Baseline Knowledge for handling Medicines Calls

What is a Medicine?

Active Ingredient or Drug

Excipients – vehicle, bulking agent, tablet coating, capsule shell, colours, flavouring, stabiliser, pH adjuster ……

Form – tablet, capsule, suppository, eye drops, cream, patch, inhaler, injection ……..



Naming medicines

Generic Brand

Amoxicillin Amoxil ®

Salbutamol Ventolin ®

Fluoxetine Prozac ®

Omeprazole Losec ®

Mefloquine Lariam ®



Naming medicinesrINN - Internationally used naming system

introduced in June 2004

British Approved Name (BAN)

Recommended International Non-proprietary Name (rINN)

Amoxycillin Amoxicillin

Dothiepin Dosulepin

Frusemide Furosemide

Lignocaine Lidocaine



Legal classification of medicines

General Sales List GSL

May be sold in general shops e.g. Paracetamol

Pharmacy OnlyP

May be sold in a pharmacy but not a general shop e.g. Zantac

Prescription OnlyPOM

May only be supplied on prescription e.g. Amoxicillin



Controlled Drugs (CDs)

Class A Heroin, LSD, ecstasy, morphine, remifentanil, Class B if injections

Class B Amphetamines, barbiturates, codeine, pentazocine, pholcodine

Class C Anabolic steroids, cannabis, growth hormone, clenbuterol

Misuse of Drugs Act 1971 – Controlled Drugs harmful when misused. Act prohibits production, supply or possession

Post Shipman - CD regulations strengthened eg returning CDs


Baseline Knowledge for handling Medicines CallsMarketing Authorisation “Product Licence”

www.mhra.gov.uk

Issued by Medicines & Healthcare Products Regulatory Agency

Product licenses granted if three questions have been fully answered by manufacturer - Safety, Quality, Efficacy



Key aspects in Summary of Product Characteristics (SPC) and Patient information leaflet (PIL) www.medicines.org.uk Large print and Braille PILs to be available

Prescribing within the product licence is the responsibility of the doctor

Patient must give informed consent if medicine is unlicensed or used “off label”

Marketing Authorisation “Product Licence”


Workshop 2 What is a Medicine?

The brand name of the product

The name of the active ingredient

The strength of the active ingredient

The Product Licence number

Look at the sample packs of medicines. Can you find….?

The expiry date

The name of the manufacturer

The legal category

The batch number

The dosage form



Off LabelUK product licence but

being used for an indication / at a dose / by a route not in the licence

No LicenceNo UK product licence

Methotrexate for asthma and lupus

Sodium valproate for prevention of migraine

Thalidomide

Melatonin

Most herbal products

Unlicensed Medicines



Newly licensed

Monitored intensively by Commission for Human Medicines (CHM) which reports to MHRA

Black triangle status usually reviewed after 2 years

Black Triangle medicines



NEWER DRUGS & VACCINES ()

All ADRs even if

Not certain that drug has caused it

Reaction well known

Other drugs at same time

ESTABLISHED DRUGS& VACCINES

All serious ADRs

Fatal, life threatening or disabling

Prolonged hospital stay

Even if well known

Yellow Card Reporting Scheme



Pilot scheme launched Jan 2005

Patients can report suspected adverse effects www.yellowcard.gov.uk Patient report forms from 4000 GPs in pilot or MHRA

Help MHRA understand the patient experience and perspective of suspected adverse effects

Patients can view anonymous data on website

Patient reporting to Yellow Card Scheme



Known as the ‘Black List’

Pricing Prescription Authority (PPA) will not reimburse dispensing cost.

NHS

Medicines that may not be prescribed in the NHS



Certain foods considered medicines in specific conditions.

Cost of dispensing reimbursed only if GP has endorsed script “ACBS

ACBSe.g.Wysoy for milk protein

sensitivity

Borderline substances



Homeopathy

Complementary Medicines

Herbal Medicine

Safe to use with conventional

medicines

May interact with conventional

medicines



In the UK, herbal products are either foods or medicines.

New legislation from August 2005 placing stricter controls on the levels of vitamins and minerals in food supplements.

Food supplements



Doctor BNF

Dentist Dental Formulary

District Nurse / Health Visitor qualified as a Nurse Prescriber

Nurse Prescribers’ Formulary

Nurse / Midwife qualified as an Extended Formulary Nurse Prescriber

Nurse Prescribers’ Extended Formulary

Who can prescribe medicines?



Voluntary partnership between doctor/dentist and supplementary prescriber to implement a clinical management plan with the patient’s agreement.

Prescribe all GSL, POM and CDs within the clinical management plan.

Pass approved training. Currently Authorised Proposed

NurseMidwife

Pharmacist

PhysiotherapistsRadiographers

Chiropodists, Optometrists

Supplementary Prescribing



New legislation to improve access to medicines

No individual prescription but Dr signs instructions for Specific Patient Group

Named health professional authorised to:

Supply a pre-labelled, fixed quantity medicine or

Administer fixed quantity medicine

Supply by PGD

Casualty

Minor Injuries Clinic

Walk-In Centre

Family Planning Clinic

Genito-Urinary Clinic

Ante-Natal Clinic

Diabetic Clinic

and more…

Patient Group Direction (PGD)



Pregnancy Breastfeeding Infants/children Elderly Patients on ‘high

risk’ medicines Renal problems Liver problems

Adverse Drug Reactions - at risk patient groups



More likely if taking several medicines Interactions can occur between conventional

medicines and

Drug Interactions

One drug modifies the effect of a second drug

Other conventional medicines

Foods

Herbal medicines Alcohol

Illicit/street drugs Food supplements


Primary resources for Medicines Calls – not in CAS system



Other support for medicines calls

NHS Direct in-house resources Health Information Specialists Health Information library

UK Medicines Information.

Your local centre is

Name…

Phone number….



Session Timetable






What Next?

More practice and hands-on training

All Nurse Advisors

6 hours – Handling Medicines Calls

All Health Information staff

6 Hours – Handling Medicines Calls

3 Hours – Oral contraception


What Next?

…..and More

Further skills sessions for HIAs and NAs• Medicines in Pregnancy and Breastfeeding• Oral Contraception and EHC• Travel Medicines• Complementary and Alternative Medicines• eBNF and eMC – further skills• Immunisation


Learning Outcomes

1. Have an overview of NHS Direct’s Pharmacy and Medicines Services

2. Have an overview of UK Medicines Information Services, National Poisons Information Service and Community Pharmacy Services

3. Have a baseline knowledge for handling Medicines and Poisons Calls

introduction to medicines, poisons and pharmacy calls ruth cheema medicines information pharmacist...

Documents

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