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THE STATE HOSPITALS BOARD FOR SCOTLAND

MEDICINES COMMITTEE 12 MONTH REPORT

1 JULY 2019 – 30 JUNE 2020

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Contents Page

1. Core Purpose of Committee 2

2. Summary of Core Activity for the last 12 months 2

3. Comparison with Last Year’s Planned QA/QI Activity 3

4. Performance against Key Performance Indicators 4

5. Quality Assurance Activity 5

6. Quality Improvement Activity 11

7. Planned Quality Assurance and Quality Improvement for the next year 11

8. Next review date 12

Appendix 1 Clinical Governance Arrangements 13

Appendix 2 Medicines Committee - Actions from Work Plan 15

Appendix 3 Medicines Committee - Guidelines and Standards Action Plan 19

1 Core Purpose of Committee In line with Healthcare Improvement Scotland guidance for Area Drug and Therapeutics Committees the purpose is to provide professional advice, clinical advice and leadership that supports safe, clinically effective, cost effective and patient centred medicines governance. The work plan fits with the hospital Quality Strategy for safe (appropriate clinical governance), effective (health improvement – physical and mental health) and person centred care at every point in the patient pathway. 2 Summary of Core Activity for the last 12 months The committee has a running workplan around 3 main areas; Medicines Management, Clinical Effectiveness and Safe Use of Medicines (see Appendices 1 and 2). Continuous review and monitoring in all these areas is integral to delivering on safe, effective and patient centred care. Specific highlights to these include: 2.1 Covid-19 Medicine Requirements There were a number of medicine process changes required during the pandemic including resilience planning for loss of Pharmacy staff. Preparatory work was also undertaken in case the hospital was required to deal with more seriously physically ill patients. This included ensuring there were stocks of certain medicines for respiratory illness, an oxygen cylinder supply and End of Life Care medicines. 2.2 Medicine Supply Shortages/EU Exit The Department of Health and Social Security planned continuity of supply of medicinal products to UK in case of a no deal EU Exit. This included securing freight, buffer stocks, stock piling and regulatory flexibility. Medicines to be prioritised if port disruption. Transport arrangements would be made for medicines that couldn’t be stockpiled. List of manufacturers with 6 weeks plus stockpile reviewed regularly. They also created a UK Medicines Shortages Response Group (MSRG) with Scottish representatives. In addition, a Scottish Medicines Shortages Response Group (MSRG -Sco) was established. Locally, national information and local intelligence was used to address both supply and logistic issues. A Medicine Supply Alert Notice system for shortages was introduced from Scottish Government (graded 1-4 low to high). 3 and 4 come with clinical advice for NHS. Level 1 and 2 alerts managed locally by Pharmacy/Medicines Committee. These have continued even without a no deal EU Exit in March. The State Hospital has created an action plan log for those relevant to the hospital. 2.3 Expenditure Medicine expenditure monitoring and savings have continued throughout the year even with additional medicine requirements during Covid-19.

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2.4 Clozapine contract switch and change to ward supply processes At the start of 2019 there was a national contract switch of supplier for the antipsychotic clozapine. This included a change of clozapine monitoring service for regular blood monitoring and results. The implementation involved a rolling programme across Health Boards. The State Hospital underwent a smooth transition over in August 2019 including appropriate information governance processes. 2.5 Clinical Audit There was another successful of year of Clinical Audit projects which is detailed in section 5 – Quality Assurance. 2.6 Medication Incident Review Group This has continued over the last 12 months with increased staff feedback now in place. It also resulted in a piece of work being undertaken by Practice Development around observation of some medicine administration practices at ward level. 2.7 Pharmaceutical Waste Disposal In collaboration with Infection Control Committee a new procedure was approved and implemented around disposal of pharmaceutical waste. Each ward has now a pharmaceutical waste bin in situ instead of returning medicines to St John’s Hospital Pharmacy on an adhoc basis for them to dispose of. 2.8 Electronic Prescribing There has been ongoing discussion with NHS Lothian on collaboration to implement electronic prescribing. This has involved discussions with Scottish Government. A draft business case has been to the Senior Management Team but still requires details of longer term maintenance costs and e-Health agreement yet to be agreed before final sign off. This work was suspended due to Covid-19 but will be being picked up again now. 2.9 Non-Medical Prescribing (Pharmacist) Framework An updated framework has been agreed for pharmacist non-medical prescribers to input to both some physical and mental health medicine prescribing within their competencies. 2.10 Falsified Medicines Directive Ongoing discussions with hospital medicine supplier (NHS Lothian) on implementation of the Falsified Medicines Directive to ensure all medicines that are received into the hospital are validated as genuine. This will be formalised once a new version of the medicine management system is introduced within NHS Lothian along with the electronic prescribing function. With suspension of the electronic prescribing work stream this is likely to delay this too. 3 Comparison with Last Year’s Planned QA/QI Activity Table 1: Comparison with Last Year’s Planned Activity

Planned Activity from 2019 Report Actual Activity

Overseeing a switch of clozapine supplier and monitoring system due to national control change. This involved Information Governance considerations.

A national rolling programme of Health Boards switching over to a new contract was undertaken. The State Hospital moved over End August 2019.

Review of the way in which clozapine tablets dispensed to the wards

Clozapine tablets historically have been dispensed as individual named patient items. A move toward ward stock supplies and on site monitoring of blood results was implemented April 2020.

Safe Use of Medicines Policy and Procedures review. This is a large document (> 100 pages) containing all procedures relating to medicines in the hospital

This is undergoing a complete format transformation and due to Covid-19 pressures the work was put on hold. Final re-drafting has now begun and stakeholder consultation planned August 2020.

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Planned Activity from 2019 Report Actual Activity

Independent (non-medical) Pharmacy Prescribing Framework update

An updated framework covering both physical and mental health, within prescribing criteria, was approved June 2020.

Progressing Electronic Prescribing Meetings and discussions with NHS Lothian and the Scottish Government continued through 2019/20 to progress The State Hospital Full Business and Case and agreed collaboration with NHS Lothian. Meetings and discussions resumed June 2020.

EU Exit planning – Medicine Supplies Risk assessment and resilience work undertaken for potential medicine supply shortages. Log of TSH actions against Scottish Government Medicine Supply Alert Notices created.

Progressing Falsified Medicines Directive Implementation

Risk Assessment completed and is included in Corporate Risk Register for TSH not complying with EU Directive from February 2019. Collaboration on-going with NHS Lothian (hospital medicine supplier) to implement once an updated version of medicine management software received with electronic prescribing update. Accepted across NHS Scotland that low risk of falsified medicines getting into NHS supply chain.

4 Performance against Key Performance Indicators There are currently no key performance indicators related to medicines use that the hospital reports on. In the Service Level Agreement for pharmacy services however there are various criteria measured against. One of these is for each patient to receive a Pharmacy report for their 6 monthly case conference review. This includes a review of their current medication (both mental and physical health) and record of any changes and response to medication over the previous 6 months. In addition, it highlights use of high dose or multiple use antipsychotics, mental health consent to treatment adherence and a reminder to review any intramuscular as required medication for acute behavioural disturbances. Recommendations also cover suggestions for new therapies and regimes. The Hub Clinical Pharmacist also offers all patients a summary sheet of their medication and undertakes a 1:1 consultation about their treatment. As the graph below shows most months show a 100% report completion rating. March and April were exceptional this year due to Covid-19 impact.

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0%10%20%30%40%50%60%70%80%90%

100%

Pharmacy report for Case Review

Hospital Wide

Arran

Iona

Lewis

Mull

Graph 1: Pharmacy report for Case Review

5 Quality Assurance Activity

5.1 Medicine Usage Medicines Expenditure Monthly invoices continue to be checked and authorised by Pharmacy against NHS Lothian Medicines Management reports. A live electronic link to NHS Lothian streamlines the medicine ordering process. Table 2: Medicines Expenditure

2019/20 Full financial year

1st quarter 2020/21

Stores £139,211 £35,048

Named Patient Dispensing £18,255 £848

Total £157,766 £35,896

For the year 2019/20 the medicines budget contributed to hospital savings. Graph 2: Medicines Budget

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For 2020/21 so far the medicines budget has exceeded the savings target although there are still a number of potential pressures with regard medicine shortages resulting in more expensive alternatives being accessed. Additional medicines for Covid-19 and oxygen cylinder rental have so far not impacted significantly. Currently the top monthly expenditure continues to include clozapine and some other atypical antipsychotics (olanzapine, aripiprazole, paliperidone), vitamin D, nicotine replacement therapy. Some individual patient physical health items are also present including anticonvulsants. Due to medicine supply shortages, sertraline (an antidepressant) and valproic acid (mood stabiliser) costs rose. Level of stock holdings on the wards are reviewed each week by the pharmacy top-up service and monitored via medicines management issue reports. Prescribing reports The number of patients receiving high dose and multiple antipsychotics continues to be monitored plus anti-microbial, controlled drug and non-formulary usage reports are reviewed. No areas for concern. Unlicensed/Off Label Prescribing The list of unlicensed and off label medicines accepted for use within the hospital is available on the intranet and is regularly updated. The Medicines Committee reviews new requests for unlicensed or off label medicines (as per hospital policy). Since last year’s report there have been 2 unlicensed and 1 off label request. These were all for physical health medicines. Peer Approved Clinical System (PACS) Tier 2 Applications These include individual requests for medicines not routinely approved for use within NHS Scotland. Each individual clinical case must have support from a peer prescriber then the application is taken to a local panel for approval. Two submissions were approved in the last 12 months, both for 2 types of antipsychotics. Medication incidents Between 1 July 2019 and 30 June 2020 there were 24 medication incidents reported on Datix. Table 3: Medication Incident Type

Incident Type Number of Incidents

Medicine Administration Incident 9

Medication Dispensing Incident 0

Medicine Prescribing Incident 4

Medicine Supply Incident 7

Medicine Other 4

Total 24

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Arran 1 Arran 2 Iona 1 Iona 2 Iona 3 Lewis 1 Lewis 2 Lewis 3 Mull 1 Mull 2 Other Total

2016/17 8 1 2 4 4 1 0 4 7 5 1 39

2017/18 6 4 7 4 2 1 3 1 3 3 0 34

2018/19 7 6 6 6 5 3 2 0 5 2 1 43

2019/20 2 2 1 3 0 0 3 0 2 7 4 24

0

5

10

15

20

25

30

35

40

45

50

Incidents Reported by Ward

Graph 3: Incident Reported by Ward

Learning points shared from the Medication Incident Review Group and the Practice Development Observational Drug Administration Audit in this period included:

Introduction of training for the role of the 2nd nurse at administration rounds.

Two members of nursing should be checking and signing controlled drug and recorded drug totals together

Ensure every rewritten prescription sheet is double checked by a second member of staff

New procedure for supply of benzodiazepines introduced (although this initially introduced new incidents from the hospital supplier)

Check availability of medicines for new admissions out of hours, especially higher priority ones

New Pharmaceutical waste bins for medicines only. No sharps, razors etc 5.2 Clinical Effectiveness Of the 23 Clinical Audit projects undertaken by Clinical Effectiveness in 2019/20 it should be noted that 10 of these were related to medicines and overseen through the Medicines Committee. 5.2.1 Clinical Audit Projects - for the reporting period of this report the following audits were carried out. Local - other than the Safe Administration of Medicines baseline audit these are all regular re-audit. 1. Consent to Treatment Adherence

Regular audit against Mental Welfare Commission Code of Practice Guidance. No major concerns.

Reminder on a T2B form best to specify the actual medication rather than broad classes.

2. Medicine Trolley

Excellent results of compliance with policy standards around layout to reduce risk of medication incidents.

3. Medicine Fridge Temperature Recording

Monitoring being completed although one ward had not reported when temperature out with limits.

Recording log standardised across the hospital.

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4. Lithium Monitoring

Patients receiving appropriate monitoring.

5. Safe Administration of Medicines Observational Audit

Role of observing nurse at medication rounds to be added to policy and at induction.

Improve witness recording of controlled drugs and recorded drug checks.

6. Antimicrobial Audit against formulary guidance

Data collected. Report delayed due to Covid-19. With specialist Lanarkshire antimicrobial pharmacy team.

7. Use of Psychotropic PRN (as required) Medicines

Data collected. Report to next Medicines Committee. National – Prescribing Observatory in Mental Health (POMH) These are national benchmarking projects that The State Hospital now participates in as part of the Forensic Network (FN code 95). The funding, co-ordination and data input of the projects sits with The State Hospital. Primarily these are facilitated by the Clinical Effectiveness Department. Junior medical staff are often involved with the data collection. Data is also shared through the Forensic Network Inter-regional Group plus the FN Pharmacy Group. 1. Assessment of the side-effects of depot/LAI antipsychotics

The practice standards for this audit were derived from NICE Guideline CG178 Psychosis and schizophrenia in adults: prevention and management plus Healthcare Improvement Scotland (2013): Management of Schizophrenia. Data was submitted for 8,270 patients UK wide. 72 patients were from 7 sites in the Forensic Network. There was a wide variety of results across the Forensic Network sites but this year some community sites were included for the first time. Broken down, The State Hospital (95.001) evidenced 100% review of side effects. Graph 4: Performance against the practice standard

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2. Monitoring of Patients Prescribed Lithium

This is the 4th time the network has completed the lithium monitoring project (2011, 2013 and 2016 previously). The total national sample (TNS) this time was 5,817 patients with 4 sites from the Forensic Network taking part (9 patients). In 2016 seven sites participated with 30 patients. It would appear a number of areas are carrying out their own local lithium audits so declined this time round. Lithium prescribing would seem also to be on the decline. The practice standards for audit were derived from NICE for bipolar disorder and included measures/tests that should be completed before lithium initiation and for maintenance. These included renal function, thyroid function tests, calcium, weight, lithium levels. For maintenance treatment 8/9 patients within the Forensic Network had received 2 or more lithium tests recorded in the previous year which met the standard. This placed the Network above the overall TNS result.

8/9 patients had appropriate renal function tests and weight/BMI recorded.

7/10 patients had appropriate thyroid function tests.

6/10 patients had appropriate serum calcium results (this was an improvement from 2016).

All of these, including the calcium, were above the overall TNS results. Broken down, The State Hospital (95.001) performed well across all the tests. Graph 5: Performance against the practice standard

3. The Use of depot/long-acting injectable antipsychotic medication for relapse prevention

The practice standards for this project focuses on documentation contained in the care plan and includes regular review of the medication. Data was submitted for 7,506 patients UK wide, 83 of those from 8 sites in the Forensic Network (only 3 sites in 2017 baseline). Overall for the Forensic Network: For those treated with a depot/LAI for 6 months to one year:

89% (16/18) had a clear rationale documented

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For those treated for more than one year:

89% (49/55) had a medication review documented. In only 1 case was a response not noted. This had improved from baseline

Side effect recording had however fallen but by less than 10% The graph below details The State Hospital (95.001) compared with other sites. Graph 6: Practice Standards

4. Antipsychotic prescribing in patients with a Learning Disability Unfortunately, due to Covid-19 data collection and submission was not possible within the time scales 5.2.2 Implementation of National Clinical Guidelines & Standards Over the last 12 months (1 July 2019 to 30 June 2020), there were 59 guidelines and standards reviewed by the Medicines Committee. This has increased from 46 in the last review period. 52 NICE Medication Technology Appraisals (MTAs), 5 NICE guidelines and 1 Healthcare Improvement Scotland (HIS) Rapid Response Review were reviewed. 54 documents were deemed to be either not relevant or were covered by a similar guideline. Of the remaining 5, all had varying degrees of relevancy to medicine provision within The State Hospital and were sent out for information purposes. There was no requirement for any recommendation reviews to be conducted over this review period. As the MTA’s were released by NICE, which is English based, both Clinical Effectiveness and Pharmacy are involved in the process of reviewing these against medications released by the Scottish Medicines Consortium and the Lothian Joint Formulary. Table 4: Guidelines/Standards reviewed

Guidelines/Standards Body No of Publications

Reviewed

No Applicable to The State Hospital

Recommendation Review required

Healthcare Improvement Scotland (HIS)

1 1 0

National Institute for Health and Clinical Excellence (NICE)

57 3 0

Scottish Government 1 1 0

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Pharmacy staff are also members of other professional groups that review guidelines/standards and can complete the medication components of these. An Action Plan detailing work ongoing from outstanding recommendations is attached to this report (Appendix 3). 5.2.3 Compliance with Mandatory e-learning Training – Safe Use of Medicines Policy Excellent compliance reported from Learning Centre with 7/10 wards with 100% staff compliance completion. Remaining wards at 93%. All but 3 wards had 1-3 staff due refresher but still positive results. 6 Quality Improvement Activity 6.1 Clinical Audit Project Action Plans Action plans, if required, are created and documented following all Clinical Audit projects and a running log kept for review at each Medicine Committee. One of the main recent pieces of work followed the Safe Administration of Medicines Observational audit via Practice Development to enhance education on the role of the second nurse at administration rounds. The aim being to make sure patients take their medicines correctly and do not have the opportunity to discard or pass on to others. This will be incorporated into the nurse induction programme and details added into the Safe Use of Medicines Policy update coming. soon. 6.2 Clozapine Supply process The clozapine supply and monitoring processes to wards were streamlined at the start of the Covid-19 pandemic and built in resilience at each stage of the process. This included Pharmacy offsite, Pharmacy onsite and at nurse administration. 6.3 Pharmaceutical Waste In collaboration with Infection Control pharmaceutical waste bins were introduced to each ward to improve disposal processes. 6.4 Controlled Drugs Following a controlled drug audit an improved system was required for pharmacist 3 monthly ward checks. This was completed as part of a TSH3030 project. 6.5 Medication Incident Feedback With the well-established Medication Incident Review Group now in place more regular feedback has been introduced to staff. 6.6 Blood Monitoring database The Health Centre’s blood monitoring database has been refreshed to make sure patients on certain medication receive the correct monitoring. There had been improved information sharing. Some work will be undertaken to make sure Covid-19 restrictions didn’t impact too severely on the data reaching the Health Centre. 7 Planned Quality Assurance and Quality Improvement for the next year Work in both Quality Assurance and Quality Improvement will continue in the 3 main areas on the work plan as outlined in Appendices 1 and 2. 1. Medicines Management 2. Clinical Effectiveness 3. Safe Use of Medicines

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Specific pieces of work will include: Table 5: Specific pieces of work

Specific work Update

Safe Use of Medicines Policy and Procedures Update

This is a large document which is undergoing a significant restructure to aid easy access to common procedures via the intranet.

Treatment of Acute Behavioural Disturbance Guidance update

A review of this guidance is required.

Unlicensed and Off label Medicines Policy Requires final approval.

Pharmacist Non Medical Prescribing With approval of a new framework the committee will oversee wider implementation.

Some items will be out with the control of the Medicine Committee but it will endeavour to contribute at a local level as necessary. Table 6: Specific work out with the control of the Medicine Committee

Specific Work Update

Medicine Supplies and EU Exit planning Planning around medicine shortages.

Electronic Prescribing To continue collaboration with NHS Lothian and aid final approval of the Full Business Case.

Compliance with Falsified Medicines Directive

Continue in line with national work plan for introduction of medicine verification when they arrive on site.

8 Next review date Ideally the next review date will be May 2021 (9 months) to fall into line with financial year time scales.

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Appendix 1

Governance arrangements for Medicines Committee Committee membership

2 x Consultant Psychiatrists (One of which is Chair)

Speciality Doctor

Senior Nurse for Infection Control/Nurse Practice Development

Clinical Effectiveness Manager

Practice Nurse Manager (Post Vacant)

Clinical Pharmacist

Lead Pharmacist

Minute Secretary Over the last 12 months there have been some losses from the committee plus periods of absence. Losses include the Practice Nurse Manager who retired (post yet to be filled) and Minute Secretary (change of role within the hospital). Two other members had periods of absence. A temporary minute secretary has recently been allocated. Role In line with Healthcare Improvement Scotland, Area and Drug and Therapeutics Committee Terms of Reference guide the role is to provide professional advice, clinical advice and leadership that supports safe, clinically effective, cost effective and patient centred medicines governance. Aims and Objectives

Advise on best practice for the safe, effective and economic use of medicines.

Advise the Senior Management Team on ethical issues relating to medicine use.

Advise, monitor and co-ordinate preparation and production of policies and procedures relating to prescribing and safe administration of medicines.

Develop implementation strategies for prescribing policies.

Develop and approve prescribing guidelines to clarify prescribing reasonability and budget issues.

Co-ordinate a system for the review and dissemination of medicine information, e.g. clinical effectiveness projects, medicines bulletins, e-learning.

Monitor trends, analysis and dissemination of learning from medication incidents

Inform and collaborate with other hospital groups on safe use of medicines including primary care colleagues.

Monitor medicines use and expenditure within clinical teams and the Hospital as a whole.

To consider the relevancy of items emanating from NHS HIS e.g. SIGN guidelines, Best Practice Statements and NICE guidelines.

Identify and prioritise a clinical effectiveness programme of work in relation to medicine projects.

Acknowledge new drug recommendations from the Scottish Medicines Consortium in relation to formulary management and availability.

Approve Patient Group Directions (PGD’s) for use at The State Hospital developed from NHS Lothian.

Support and promote the use of the Lothian Joint Formulary.

Liaise with NHS Lothian Hospital and Specialist Services Medicines Committee e.g. to share ideas, practice and new developments.

The committee will be empowered to form sub-groups to achieve its objectives.

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Meeting frequency and dates The committee meets every 2 months. In the last 12 months the committee met 5 times: August, October, December, February and June. One meeting was cancelled during the pandemic although a number of core pieces of work continued for safe use of medicines. Workplan The work plan is based around 3 key areas and results in a number of rolling standing agenda items which emanate from the Quality Strategy for safe (appropriate clinical governance), effective (health improvement – physical and mental health) and person centred care. These are: 1. Medicine Management

Expenditure

Formulary news/SMC recommendations

New licensed indications and products

Unlicensed/Patient Treatment Requests

Product Supply problems

2. Clinical Effectiveness

Local projects

National Prescribing Observatory in Mental Health Audits

Audit improvement plans

Clinical Governance Standards/Guidance 3. Safe Use of Medicines

Medication incidents

Drug safety updates/drug alerts

Policy updates and treatment guidance Other topics arising for discussion/action generally fit into one of the 3 main headings. A log of all actions is kept in an up to date action plan table. See Appendix 2. Management arrangements The committee reports directly to the Clinical Governance Group.

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Appendix 2 MEDICINES COMMITTEE - Actions from Work Plan (post June 2020 meeting) RED – Actions/updates from last meeting

Agenda Item

Action By Whom Date

Progress note

MEDICINES MANAGEMENT - Standing items

Expenditure Hepatitis C treatment rebate still awaited from National Procurement (NP) since 2018 Review of expenditure

MW/finance 2019/20 On-going

NP advice going out to HB. Looks like TSH will need to claim back via NHS Lothian. VAT query hold up. MW line manager NHSL in discussion with NHSL Finance. Credit available for 3 out of 4 patients (ex VAT). Still being finalised with Lothian. Credit looks sorted now. Just awaiting receipt. Currently within budget but some extra costs with Covid 19 stocks plus oxygen cylinder rental

Formulary news/SMC recommendations

Rolling updates On-going Clenil Modulite switch July 20

New Licensed Indications and Products

Rolling updates On-going

Unlicensed/PACS2/IPTR Unlicensed policy for review

July 20 Updated and consultation completed. With LT for IA sign off. Still awaited signed forms. To clarify who is going to approve policies now

Product Supply Problems Lorazepam injection Depakote

June 20 July 20

Monitoring stocks until available again. Unlicensed options explored Alternative being used. Hopefully back July 20

Other

Falsified Medicines Directive Hospital will need to comply with FMD Local action plan

End 2020 MW

Chief Exec and AMD aware of new timescales. In CGC report too Local plan in place to follow NHS Lothian implementation plan with JAC upgrade

EU Exit Effect on medicine supply MW

Resilience planning in place. Log of Medicine Supply Alerts with TSH actions completed and updated regularly

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Agenda Item

Action By Whom Date

Progress note

MEDICINE PROCESSES DURING COVID 19

Extra Oxygen cylinders Accessed via National Procurement To be returned to BOC at some point

With Gold Command

Review with Medical Director if need to continue to hold onsite

Mull 3 Covid-19 Medicine Supplies Leave in place until Mull3 ward stood down With Gold Command

Will require destruction

End of Life Care Medicines As above With Gold Command

Will require destruction

Critical Loss of Pharmacy Staff – resilience planning

Desk top exercise to be planned to test Aug 20 Risk Dept to assist

CLINICAL EFFECTIVENESS PROGRAMME OF WORK

- Standing items

Clinical Governance Standards/Guidelines

Compliance review End Nov SS

Latest new guidance document approved at June 20 meeting

RPS Safe and Secure Handling of Medicines for review

ALL Dec 19

Gap analysis done - approved Dec meeting Action plan in place – oxygen signage, FMD, competencies. Oxygen signage pursued

National Audits

POMH Rapid Tranquilisation Debrief to be held following administration of IM med

SS July 19

On agenda for next Patient Safety Group

Acknowledge patients preference and wishes for future episodes

SS July 19

On agenda for next Patient Safety Group

Improve physical health recording post injection

KB July 2019

This has been communicated and will be audited by CED. Format to be agreed.

POMH Lithium Improve assessment and recording of side effects (from 2018 report)

MW August 2019

MW will liaise with KB Passed to pharmacy team member – delay due to Covid19

Use of depot for relapse prevention Report received – summary SBAR required May 2020 MW Completed for June meeting. To go to FN IRG when reconvenes

Local Audits

Consent to Treatment Adherence It should be clearly indicated on the prescription sheet that the patient has a consent to treatment form.

November 2019 BP asked if it was necessary to circle T2/T3 section on the prescription sheet when the standard is to write beside the medicine if it is covered by a T2 or T3.

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Agenda Item

Action By Whom Date

Progress note

Agreement required. Current large supply of prescription sheets in stock.

The following guidance should be adhered to: ‘Where the patient gives capable consent to treatment, it is best practice to specify the actual medication(s) on form T2, rather than give broad classes. It would also be good practice to record the purpose of the medication on the form.’

NB November 2019

To be taken to MAC – not completed. Planned July 20

Ensure all 6 items in the Mental Health Code of Practice guidance are adhered to including the use of the British approved name.

NB November 2019

To be taken to MAC – not completed. Planned July 20

On a number of occasions there were psychotropic medications on the prescription sheets that were not covered by the consent to treatment form

NB November 2019

To be taken to MAC and form part of the Junior Doctor Induction. Pharmacy to be informed – final report needed to circulate round dept – received and sent

Audit to be repeated in 12 months SS Aug 20

BP asked if, in future, the data collection could be done straight into the database. Delayed (Covid19) until new Junior Doctors arrive

Audit of Scottish clozapine monitoring guidelines

A further piece of work looking to ensure that patients with high plasma glucose get a further fasting test carried out.

SS October 2019

SS to speak to CAB re local triggers for fasting glucose. Dr Mason to be contacted now.

Enquire if bowel screening can be added to monthly weight monitoring form on RiO and then brought through into CTM form.

SS October 2019

SS met with Frances but not keen on bowel screening being part of weight monitoring form – can Medicines Committee consider an alternative fix? Needs to be part of nursing care plan – refer to KB for way forward. Added to pharmacy alert about regular FBC result. Check bowel function and record on Rio

Future audits should check that a GASS has been completed every 6 months.

CED February 2020

Changes made to audit tool to capture this information – update tool agreed Dec Delayed due to Covid 19 but underway June 20

High Dose Antipsychotic Monitoring Final report completed June 20 Discussed at June meeting. Positive results. No action required

Antimicrobial audit With Lanarkshire

PRN prescribing audit For August meeting

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Agenda Item

Action By Whom Date

Progress note

Prescription Sheet Audit Final report underway

SAFE USE OF MEDICINES - Standing items

Medication Incidents Monitor incidents to review practice/policy ALL On-going

Medication Review Group now in place.

Drug Safety Update/Drug Alerts Rolling review On-going

- Other

Safe Use of Medicines Policy For review: Include procedure for giving pts meds in room. Ref. Insulin self admin

ALL Dec 19

MW/KB progressing review of policy – delayed due to Covid19. Drafts for discussion June meeting. Appendices circulated to nominated individuals for comments

Acute Behavioural Disturbance guidance update

For review Mar 2020 Mar 20 Delayed due to Covid but interim update info sent around use of benzodiazepines

Antipsychotic monitoring and NRT guidance review

Review required June 20 JMc

No change. Extend review dates

Electronic Prescribing (HEPMA) Awareness of progress MW FBC submitted. Depends on SG funding. Working with NHS Lothian. Jamie Pitcairn/Pharmacy progressing – funding agreed from SG. SMT to finalise decision Jan 20 - delayed

Non-medical Independent Prescribing

Agree frameworks for local use ALL Nov 2019

MW met with prescribers and liaising with GP on support ideas. Draft framework being worked on. Approved June meeting

Buccal midazolam Explore switching rectal diazepam in medical emergency bags to buccal midazolam

May 2020

MW to consult colleagues in other Health Boards – paper written for Feb20 meeting. Now to go to MAC – Aug. No change at moment

AOB

Terms of reference To update current MC in line with ADTC template

MW/NB Sep 19

Discussed at June 20 meeting. Minor changes circulated for approval

Clinical Governance Report To CGC Aug 20 MW/ALL

Draft being worked on

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Appendix 3 Medicines Committee - Guidelines and Standards Action Plan

Guideline & Outstanding Recommendation

Evidence Level

Comments from Gap Analysis Person Responsible

Update (inc date) Projected Completion

Date

Royal Pharmaceutical Society – Professional guidance on the administration of medicines in healthcare settings

Reviewed by Medicines Committee – August 2019

15.5.2 Any calculations needed are double checked where practicable by a second person and uncertainties raised with the prescriber or a pharmacy professional.

The need for calculations to be double checked will be written into the updated policy.

Morag Wright 5/2/2020 - Written in to draft policy that will be out for consultation summer 2020

June 2020

Royal Pharmaceutical Society – Professional guidance on the safe and secure handling of medicines Reviewed by Medicines Committee – December 2019

3.7 Organisational and legal requirements such as the Falsified Medicines Directive, Standing Financial Instructions and data protections are complied with.

Partly achieved. Current national setting is non-compliance with FMD. This should be resolved during 2020 at which time we will adhere.

Morag Wright 5/2/2020 - TSH risk assessment updated. Still accepting risk in line with other Health Boards

December 2020

3.63 Training is given to those handling any medicine and, where appropriate, competency checks are carried out at suitable intervals.

Partial compliance. PDR process. Revalidation. On line learning modules are completed annually and are monitored by the learning centre. Details of staff completion are sent to line manager for action. However no competency check – to be taken forward.

Karen Burnett 6/2/2020 - Discussion has taken place and competency checks will not be undertaken at present. This will be revised with the introduction of HEPMA and subsequent roll out. When the SAM policy is revised the revision of the online module will also take place, therefore theoretical competency will be tested.

March 20201

A7 Areas where oxygen is stored or used display appropriate signage

Estates storage. Ward treatment room. H & S checks. Signage to be updated.

Kenny Andress/ Brian McLean

Signage to be in place by end of June 2020

June 2020