Medicines reconciliation in comparison with NICE guidelines across secondary care mental health organisations

Background Medicines reconciliation-identifying and maintaining an accurate list of a patient's current medications-should be undertaken at all transitions of care and available to all patients. Objective A self-completion web survey was conducted for chief pharmacists (or equivalent) to evaluate medicines reconciliation levels in secondary care mental health organisations. Setting The survey was sent to secondary care mental health organisations in England, Scotland, Northern Ireland and Wales. Method The survey was launched via Bristol Online Surveys. Quantitative data was analysed using descriptive statistics and qualitative data was collected through respondents free-text answers to specific questions. Main outcomes measure Investigate how medicines reconciliation is delivered, incorporate a clear description of the role of pharmacy staff and identify areas of concern. Results Forty-two (52 % response rate) surveys were completed. Thirty-seven (88.1 %) organisations have a formal policy for medicines reconciliation with defined steps. Results show that the pharmacy team (pharmacists and pharmacy technicians) are the main professionals involved in medicines reconciliation with a high rate of doctors also involved. Training procedures frequently include an induction by pharmacy for doctors whilst the pharmacy team are generally trained by another member of pharmacy. Mental health organisations estimate that nearly 80 % of medicines reconciliation is carried out within 24 h of admission. A full medicines reconciliation is not carried out on patient transfer between mental health wards; instead quicker and less exhaustive variations are implemented. 71.4 % of organisations estimate that pharmacy staff conduct daily medicine reconciliations for acute admission wards (Monday to Friday). However, only 38 % of organisations self-report to pharmacy reconciling patients' medication for other teams that admit from primary care. Conclusion Most mental health organisations appear to be complying with NICE guidance on medicines reconciliation for their acute admission wards. However, medicines reconciliation is conducted less frequently on other units that admit from primary care and rarely completed on transfer when it significantly differs to that on admission. Formal training and competency assessments on medicines reconciliation should be considered as current training varies and adherence to best practice is questionable.

Business strategy and the environment in a traditional manufacturing sector

This research is concerned with the relationship between business strategy and the environment within traditional sectors. It has sought to learn more about the strategic environmental attitudes of SMEs compared with large companies operating under the same market conditions. The sector studied is the ceramics industry (including tableware & ornamental-ware, sanitary ware & tiles, bricks, industrial & advanced ceramics and refractories) in the UK and France. Unlike the automotive, oil, chemical, steel or metal processing sectors, this industry is one of the few industrial sectors which has rarely been considered. The information on this sector was gathered by interviewing people responsible for environmental issues. The actual programme of valid interviews represents approximately a quarter of the UK and French ceramics industry which is large enough to enable a quantitative analysis and significant and non-biased conclusions. As a whole, all companies surveyed agreed that the ceramics activity impacts on the environment, and that they are increasingly affected both by environmental legislation, and by various non-legislative pressures. Approaches to the environmental agenda differ significantly among large and small companies. Smaller companies feel particularly pressed both by the financial costs and management time required to meet complex and changing legislation. The results of this survey also suggest that the ceramics industry sees environmental issues in terms of increased costs rather than new business opportunities. This is due principally to fears of import substitution from countries with lower environmental standards. Finally, replies indicate that generally there is a low level of awareness of the current legislative framework, suggesting a need to shift from a regulatory approach to a more self-regulated approach which encourages companies to be more proactive

An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital

Aims: To determine the incidence of unintended medication discrepancies in paediatric patients at the time of hospital admission; evaluate the process of medicines reconciliation; assess the benefit of medicines reconciliation in preventing clinical harm. Method: A 5 month prospective multisite study. Pharmacists at four English hospitals conducted admission medicines reconciliation in children using a standardised data collection form. A discrepancy was defined as a difference between the patient's preadmission medication (PAM), compared with the initial admission medication orders written by the hospital doctor. The discrepancies were classified into intentional and unintentional discrepancies. The unintentional discrepancies were assessed for potential clinical harm by a team of healthcare professionals, which included doctors, pharmacists and nurses. Results: Medicines reconciliation was conducted in 244 children admitted to hospital. 45% (109/244) of the children had at least one unintentional medication discrepancy between the PAM and admission medication order. The overall results indicated that 32% (78/244) of patients had at least one clinically significant unintentional medication discrepancy with potential to cause moderate 20% (50/244) or severe 11% (28/244) harm. No single source of information provided all the relevant details of a patient's medication history. Parents/carers provided the most accurate details of a patient's medication history in 81% of cases. Conclusions: This study demonstrates that in the absence of medicines reconciliation, children admitted to hospitals across England are at risk of harm from unintended medication discrepancies at the transition of care from the community to hospital. No single source of information provided a reliable medication history.

Reducing medicines waste in the community

There is increasing concern at the amount and cost of prescribed medicines that are unused or wasted and then have to be disposed of. Previous studies have used health promotion and Dispose Unwanted Medicines Properly campaigns targeted at the patient to describe and quantify the annual cost of waste. The reasons patients return unused drugs to pharmacies have also been explored. The paper focuses on patient explanations for not needing medication; categorized as: over-collection in the past, self-management strategies, changes in medical condition, other changes in patient circumstances, or the repeat medicines policy at the surgery. The aim of the original study was to make a measurable change in prescribed medicines with a reduction in medicines wastage, whilst at the same time achieving improved standards of pharmaceutical care. Information on patient needs and behaviour came from consultation in the pharmacy monitoring forms and interview. The study was based on two medical practices in the West Midlands, UK, comparing an outer city and an inner city population. The participants were general practitioners, pharmacists and 350 repeat prescription patients. Prescriptions were issued for two three-month periods. The outcome was that 23.8% of the prescribed items were not dispensed, at a value of £13.1K, 58% of the medications that would be expected to be regularly supplied were collected. The study suggests that closer professional management at the point of dispensing and an understanding of patient experiences can help reduce the amount of unwanted medication collected by patients.

Medicines management across the primary-hospital healthcare interface: a study of paediatric patients

A comparison of medicines management documents in use by NHS organisations in the West Midlands confirms that there are important differences between the primary care and hospital sectors in respect to medicines management interface issues. Of these, two aspects important to paediatric patients have been studied. These are the transfer of information as a patient is admitted to hospital, and access to long-term medicines for home-patients. National guidance provided by NICE requires medication reconciliation to be undertaken on admission to hospital for adults. A study of paediatric admissions, reported in this thesis, demonstrates that the clinical importance of this process is at least as important for children as for adults, and challenges current UK guidance. The transfer of essential medication information on hospital admission is central to the medication reconciliation process. Two surveys of PCTs in 2007 and again in 2009 demonstrate that very few PCTs provide guidance to GPs to support this process. Provision of guidance is increasing slowly but remains the exception. The provision of long-term medicines for children at home is hindered by this patient population often needing unlicensed drugs. Further studies demonstrate that primary care processes regularly fail to maintain access to essential drugs and patients and their carers frequently turn to hospitals for help. Surveys of hospital medical staff (single site) and hospital nurses (six UK sites) demonstrates the activity these healthcare workers perform to help children get the medicines they need. A similar survey of why carers turn to a hospital pharmacy department for urgent supplies (usually termed rescue-medicines) adds to the understanding of these problems and supports identifying service changes. A large survey of community pharmacies demonstrates the difficulties they have when dispensing hospital prescriptions and identifies practical solutions. This programme concludes by recommending service changes to support medication management for children.

Returned medicines:Waste or a wasted opportunity?

Background: Re-use of unused medicines returned from patients is currently considered unethical in the UK and these are usually destroyed by incineration. Previous studies suggest that many of these medicines may be in a condition suitable for re-use. Methods: All medicines returned over two months to participating community pharmacies and GP surgeries in Eastern Birmingham PCT were assessed for type, quantity and value. A registered pharmacist assessed packs against set criteria to determine the suitability for possible re-use. Results: Nine hundred and thirty-four return events were made from 910 patients, comprising 3765 items worth £33 608. Cardiovascular drugs (1003, 27%) and those acting on the CNS (884, 24%) were most prevalent. Returned packs had a median of 17 months remaining before expiry and one-quarter of packs (1248 out of 4291) were suitable for possible re-use. One-third of those suitable for re-use (476 out of 1248) contained drugs in the latest WHO Essential Drugs List. Conclusion: Unused medicines are returned in substantial quantities and have considerable financial value, with many in a condition suitable for re-use. We consider it appropriate to reopen the debate on the potential for re-using these medicines in developing countries where medicines are not widely available and also within the UK. © The Author 2007, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

An analysis of returned medicines in primary care

Objective: The number of pharmaceutical items issued on prescription is continually rising and contributing to spiralling healthcare costs. Although there is some data highlighting the quantity, in terms of weight of medicines returned specifically to community pharmacies, little is known about the specific details of such returns or other destinations for wasted medications. This pilot study has been designed to investigate the types and amounts of medicines returned to both general practices (GPs) and associated local community pharmacies determining the reasons why these medicines have been returned. Method: The study was conducted in eight community pharmacies and five GP surgeries within East Birmingham over a 4-week period. Main outcome Measure: Reason for return and details of returned medication. Results: A total of 114 returns were made during the study: 24 (21.1) to GP surgeries and 90 (78.9) to community pharmacies. The total returns comprised 340 items, of which 42 (12.4) were returned to GPs and 298 (87.6) to pharmacies, with the mean number of items per return being 1.8 and 3.3, respectively. Half of the returns in the study were attributed to the doctor changing or stopping the medicine; 23.7 of returns were recorded as excess supplies or clearout often associated with patients' death and 3.5 of returns were related to adverse drug reactions. Cardiovascular drugs were most commonly returned, amounting to 28.5 of the total drugs returned during the study. Conclusions: The results from this pilot study indicate that unused medicines impose a significant financial burden on the National Health Service as well as a social burden on the United Kingdom population. Further studies are examining the precise nature of returned medicines and possible solutions to these issues. © Springer 2005.

The role of trust in the transition from traditional to electronic B2B relationships in agri-food chains

E-business adoption rates in the agri-food sector are rather low, despite the fact that technical barriers have been mostly overcome during the last years and a large number of sophisticated offers are available. However, concerns about trust seem to impede the development of electronic relationships in the agri-food chains as trust is of particular importance in any exchange of agri-food products along the value chain. Drawing on existing research, characteristics and dimensions of trust are initially identified both in traditional and in electronic B2B relationships and a typology of trust is proposed. The aim of the paper is to provide an overview of the implementation and use of trust elements that e-commerce offers dedicated to agri-food sector. This assessment will show the current situation and discuss gaps for further improvement with the objective to facilitate the uptake of e-commerce in agri-food chains. © 2009 Elsevier B.V. All rights reserved.

An investigation of medicines returned to general practitioners and community pharmacies

Focal points: All returned medicines were monitored in eight community pharmacies and five general medical practices over a four-week period Returns were analysed for the type, quantity, absolute cost of the medicines, original quantity and date dispensed together with the reason for return A total of 298 items was returned to pharmacists and the reason for the return was a change or stop of therapy in 56 per cent of cases; 66 per cent of these were prescribed in a quantity of one month or greater A total of 42 items was returned to GPs and the reason for the return involved a change or stop of the therapy in 54 per cent of cases; 69 per cent of these were prescribed in a quantity of one month or greater Measures to implement a procedure to limit prescribed quantities upon initiation of therapy should help to reduce medicines wastage

Herbal medicines:physician's recommendation and clinical evaluation of St.John's Wort for depression

Why some physicians recommend herbal medicines while others do not is not well understood. We undertook a survey designed to identify factors, which predict recommendation of herbal medicines by physicians in Malaysia. About a third (206 out of 626) of the physicians working at the University of Malaya Medical Centre ' were interviewed face-to-face, using a structured questionnaire. Physicians were asked about their personal use of, recommendation of, perceived interest in and, usefulness and safety of herbal medicines. Using logistic regression modelling we identified personal use, general interest, interest in receiving training, race and higher level of medical training as significant predictors of recommendation. St. John's wort is one of the most widely used herbal remedies. It is also probably the most widely evaluated herbal remedy with no fewer than 57 randomised controlled trials. Evidence from the depression trials suggests that St. John's wort is more effective than placebo while its comparative efficacy to conventional antidepressants is not well established. We updated previous meta-analyses of St. John's wort, described the characteristics of the included trials, applied methods of data imputation and transformation for incomplete trial data and examined sources of heterogeneity in the design and results of those trials. Thirty randomised controlled trials, which were heterogeneous in design, were identified. Our meta-analysis showed that St. John's wort was significantly more effective than placebo [pooled RR 1.90 (1.54-2.35)] and [Pooled WMD 4.09 (2.33 to 5.84)]. However, the remedy was similar to conventional antidepressant in its efficacy [Pooled RR I. 0 I (0.93 -1.10)] and [Pooled WMD 0.18 (- 0.66 to 1.02). Subgroup analyses of the placebo-controlled trials suggested that use of different diagnostic classifications at the inclusion stage led to different estimates of effect. Similarly a significant difference in the estimates of efficacy was observed when trials were categorised according to length of follow-up. Confounding between the variables, diagnostic classification and length of trial was shown by loglinear analysis. Despite extensive study, there is still no consensus on how effective St. lohn's wort is in depression. However, most experts would agree that it has some effect. Our meta-analysis highlights the problems associated with the clinical evaluation of herbal medicines when the active ingredients are poorly defined or unknown. The problem is compounded when the target disease (e.g. depression) is also difficult to define and different instruments are available to diagnose and evaluate it.

Virtual manufacturing:a study of some important issues relating to the transformation of traditional manufacturing organisations

This thesis starts with a literature review, outlining the major issues identified in the literature concerning virtual manufacturing enterprise (VME) transformation. Then it details the research methodology used – a systematic approach for empirical research. next, based on the conceptual framework proposed, this thesis builds three modules to form a reference model, with the purpose of clarifying the important issues relevant to transforming a traditional manufacturing company into a VME. The first module proposes a mechanism of VME transformation – operating along the VME metabolism. The second module builds a management function within a VME to ensure a proper operation of the mechanism. This function helps identify six areas as closely related to VME transformation: lean manufacturing; competency protection; internal operation performance measurement; alliance performance measurement; knowledge management; alliance decision making. The third module continues and proposes an alliance performance measurement system which includes 14 categories of performance indicators. An analysis template for alliance decision making is also proposed and integrated into the first module. To validate these three modules, 7 manufacturing organisations (5 in China and 2 in the UK) were investigated, and these field case studies are analysed in this thesis. The evidence found in these organisations, together with the evidence collected from the literature, including both researcher views and literature case studies, provide support for triangulation evidence. In addition, this thesis identifies the strength and weakness patterns of the manufacturing companies within the theoretical niche of this research, and clarifies the relationships among some major research areas from the perspective of virtual manufacturing. Finally, the research findings are summarised, as well as their theoretical and practical implications. Research limitations and recommendations for future work conclude this thesis.

Medicines non-use in primary care

This study expands the current knowledge base on the nature, causes and fate of unused medicines in primary care. Three methodologies were used and participants for each element were sampled from the population of Eastern Birmingham PCT. A detailed assessment was made of medicines returned to pharmacies and GP surgeries for destruction and a postal questionnaire covering medicines use and disposal was used to patients randomly selected from the electoral roll. The content of this questionnaire was informed by qualitative data from a group interview on the subject. By use of these three methods it was possible to triangulate the data, providing a comprehensive assessment of unused medicines. Unused medicines were found to be ubiquitous in primary care and cardiovascular, diabetic and respiratory medicines are unused in substantial quantities, accounting for a considerable proportion of the total financial value of all unused medicines. Additionally, analgesic and psychoactive medicines were highlighted as being unused in sufficient quantities for concern. Anti-infective medicines also appear to be present and unused in a substantial proportion of patients’ homes. Changes to prescribed therapy and non-compliance were identified as important factors leading to the generation of unused medicines. However, a wide array of other elements influence the quantities and types of medicines that are unused including the concordancy of GP consultations and medication reviews and patient factors such as age, sex or ethnicity. Medicines were appropriately discarded by 1 in 3 patients through return to a medical or pharmaceutical establishment. Inappropriate disposal was by placing in household refuse or through grey and black water with the possibility of hoarding or diversion also being identified. No correlations wre found between the weight of unused medicines and any clinical or financial factor. The study has highlighted unused medicines to be an issue of some concern and one that requires further study.

Design and construction for traditional house building

This study is concerned with quality and productivity aspects of traditional house building. The research focuses on these issues by concentrating on the services and finishing stages of the building process. These are work stages which have not been fully investigated in previous productivity related studies. The primary objective of the research is to promote an integrated design and construction led approach to traditional house building based on an original concept of 'development cycles'. This process involves the following: site monitoring; the analysis of work operations; implementing design and construction changes founded on unique information collected during site monitoring; and subsequent re-monitoring to measure and assess Ihe effect of change. A volume house building firm has been involved in this applied research and has allowed access to its sites for production monitoring purposes. The firm also assisted in design detailing for a small group of 'experimental' production houses where various design and construction changes were implemented. Results from the collaborative research have shown certain quality and productivity improvements to be possible using this approach, albeit on a limited scale at this early experimental stage. The improvements have been possible because an improved activity sampling technique, developed for, and employed by the study, has been able to describe why many quality and productivity related problems occur during site building work. Experience derived from the research has shown the following attributes to be important: positive attitudes towards innovation; effective communication; careful planning and organisation; and good coordination and control at site level. These are all essential aspects of quality led management and determine to a large extent the overall success of this approach. Future work recommendations must include a more widespread use of innovative practices so that further design and construction modifications can be made. By doing this, productivity can be improved, cost savings made and better quality afforded.