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Bitter pill

Bitter pill

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With £300 million of medicines wasted each year better management is worth while, especially in a care home setting

The issue of medicines waste is well recognised. A report1 estimated the annual cost of unused medicines to the NHS was about £300 million. It was suggested that systems and processes used in care homes account for £50 million of this.
Wessex Academic Health Science Network funded a project to identify and address causes of preventable medicines waste by reviewing care home medicines waste logs. The project was delivered by the Aylesbury Vale and Chiltern Clinical Commissioning Groups’ (CCG) medicines management team.

The project
Three care homes were prioritised for the project. Care home pharmacists were resourced to:
Collate and categorise data from care home waste logs. Data was collected before and after the pharmacist started work in the care home.
Address systems within the care home that were contributing to avoidable medicines waste.
Identify system-wide issues leading to medicines waste.
At the start of the project, data from the waste logs for the participating care homes identified that approximately £43,500 worth of medicines were disposed of. Approximately £32,000 (74%) of this was avoidable.
At the end of the project, total medicine waste had reduced to £6,500. The total annualised cost saving was £37,000.
Table 1 and Figure 1 show the categories of avoidable medicines waste used and a breakdown of cost savings per category.

 

Causes of avoidable waste
The project found that lack of robust ordering processes and protocols contributed to the majority of avoidable medicines waste. This included:

  • Items that had been stopped by healthcare professionals, continuing to be ordered.
  • Incorrect items and quantities being ordered.
  • Medication not being carried forward to the next cycle.
  • When required, medication being ordered regularly and supplied in monitored dose systems.
  • Duplicate orders of the same item.
  • Specific examples are detailed (see Box 1 and Box 2).


Actions taken to reduce identified avoidable waste
Ordering
Ordering protocols were developed or reviewed to include:

  • Immediate steps to take to rectify duplicate orders.
  • Action to take when medication is stopped by the GP.
  • Necessary steps when a resident is admitted to hospital.
  • How to carry forward medication and record quantities on Medicine Administration Records (MAR) charts at the end of the cycle.
  • A checklist of documents that should be available when ordering repeat medication.
  • An error log that is audited quarterly.


Discharge
The system that operated within the care homes involved medication being re-ordered in monitored dose systems (MDS) after original packs were discarded on discharge from hospital. This was categorised as unavoidable waste.
Recommendations to the care home included continuing to use the medication in original packs until the next cycle. Reviewing and addressing system-wide processes for the supply of individual medication on discharge from secondary care would re-categorise this waste as avoidable.

‘When required’ medication
Recommendations were provided for the use and supply of medications administered as and when required.
This included a recommendation to
supply when required medication in original packs. System-wide guidance on ‘when required’ medication has been developed by the CCG to spread best practice in this area.

Training
For residents newly admitted to care homes with their own medicines, the care home processes involved discarding this medication and re-ordering. Training staff to carry out medicines reconciliation and encouraging medication reviews within a week of admission by the GP or care home pharmacist resulted in reduced waste in this area.
Training was also provided on efficient ordering processes, protocols and appropriate use of dressings, SIP (nutritional supplements) feeds, insulin and inhalers.
Communication
Communication systems between the GP practice, care home and community pharmacy were improved to synchronise ordering, ensure errors in ordering and supply were rectified quickly, and that discontinued items were removed from the medication administration record (MAR) charts.

Conclusion
Many system factors can result in medicines waste in care homes. Some of these cannot be avoided and are a part of daily care such as changes to medication. Understanding the causes of avoidable medicines waste at a local level enables specific targeted action to be taken at a care home and system wide level.
The project identified inefficient ordering systems as the main contributor to avoidable medicines waste. Commissioners, GP services and pharmacy in-reach services who support care homes to review and standardise their ordering processes can have a considerable impact on reducing waste in this area.

Reference
1.    York Health Economics Consortium and The School of Pharmacy, University of London. Evaluation of the Scale Causes and Costs of Waste Medicines. 2010. http://eprints.pharmacy.ac.uk/2605/1/Evaluation_of_NHS_Medicines_Waste__... (accessed 29 May 2015)

Seema Gadhia, Unoma Okoli and Mitta Bathia – Medicines Management Team, Aylesbury Vale and Chiltern Clinical Commissioning Groups.

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