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According to the National Patient Safety Agency (NPSA), between 2006 and 2009, 27 deaths, 68 severe harms and 21 383 other patient safety incidents relating to omitted or delayed medicines were reported.1 Some of the NPSA’s accompanying recommendations identified specific critical medicines that were required to be administered in a timely manner. Eight years have passed since the alert, and dose delays and omissions continue to constitute a large proportion of reported incidents, at 16% making up one of the major error categories, alongside wrong doses at 15%.2 The NPSA recommended a staged approach leading to more sustainable improvements over time.1 Initiatives have been implemented, including feedback- and audit-related activities, none of which have proved sufficiently effective in light of the time invested. Nursing staff have gone to extremes, including wearing tabards alerting patients and staff that they must not be interrupted during medication rounds to reduce medicine-related errors.3 An Australian study pioneered the role of a ward-based pharmacy technician over a decade ago, showing a substantial reduction in omitted doses.4 This role involved pharmacy technicians being integrated into the nursing team and facilitating medicine administration.4 This is now a well-recognised role in forward-thinking institutions around the globe, including the UK.4
With increased pressures related to assigning and retaining nursing staff, especially in rural areas, the role could not have been created at a better time. The Nursing and Midwifery Council reported having lost 1678 nurses and midwives from the register between 2016 and 2017.5 The significance of this number is reflected in the staffing shortages being experienced across the country, which create a serious risk of medication-related errors due to overworked staff. It has been found that there is an increased risk of interruption-related errors in acute medical wards.6 This comes as no surprise, as demand for ample nursing staff remains high.
In 2016, the Pharmacy Department at Lincoln County Hospital decided to recruit two pharmacy technicians into a busy medical emergency admissions unit. The role involved tasks ranging from oral and intravenous drug administration to ensuring a strict audit trail of controlled drugs. The position was implemented to ease nursing pressures and in a bid to decrease missed doses and drug errors. This was sensitively approached as a nurse-affiliated role as opposed to a replacement of the existing nursing role.
Cost implications are a critical consideration. Due to the lack of nurses available to fill the available vacancies, these new roles do not affect nursing vacancies; however, they enhance the role of those already filling such posts by freeing up nursing time and improving medicines optimisation. Unused or wasted medicines cost the NHS an estimated £100 million annually.7 One of the most common routes to wastage is not transferring patients along with their medicines, leading to reordering and wastage.7 It has been recognised that pharmacy staff can have a direct impact on this; hence, the role should prove useful in tackling wastage, thereby saving money.
The nursing staff fully accommodated the new members of the team, creating an invaluable collaboration and inspiring a possible wider implementation of the role across the Trust.
The aim of the pilot was to assess how the introduction of a pharmacy technician into a busy emergency assessment unit affected reported omitted doses and the general productivity of the ward.
The pilot commenced in August 2016 in a large district hospital located in North-East England. A 33-bed emergency assessment unit was of particular interest due to its high patient turnover. As one of the busiest wards in the hospital, it was most likely to benefit from the trial.
A position was advertised and received ample interest, but also elicited apprehension. The role required no prior experience and offered sufficient training for those who participated. Two technicians were recruited and trained within the unit. In preparation for the role, intravenous administration training was delivered via theory, practical learning and e-learning. Ward training packages were also used to ensure the baseline ward knowledge that would be expected of a newly qualified nurse. The technicians were assessed through supervised drug rounds and an intravenous training day to consolidate practical knowledge. Overall, training was delivered over 6 months while intravenous administration training took 4 weeks. Training was carried out by a senior nurse with several years of experience as a staff nurse and a clinical educator. This ensured that the pharmacy technicians felt comfortable in the new role.
After training had been completed, the two technicians were integrated into the team to cover two shifts, allowing both early and late shift workers to benefit from the new role. This ensured that there was a pharmacy technician in the unit between 06.00 hours and 22.00 hours to accommodate the 08.00, 13.00, 18.00 and 22.00 hours medication rounds. The role involved the intravenous and oral administration of drugs, pharmacy returns, ensuring that medicines moved with patients, a strict audit trail of controlled drugs, second-checking and, most importantly, highlighting any drugs that were not available to the pharmacy team during pharmacy ward rounds, enabling the pharmacy team to prioritise critical medication.
Data were obtained over a 30-day period between August and September 2016, with each ward round being based on a bay containing an average of seven patients. Within the first month of the observation period, the collected data showed that nurses spent on average 63 min on their medication rounds, with an average of four interruptions per ward round (see online Supplementary Table). Each nurse was responsible for an average of eight patients across four bays in a 33-patient ward. The ‘perfect medication round’ with no interruptions lasted 23 min, while the longest medication round with a total of 11 interruptions lasted 116 min. Three months after the pilot started, incident reports were substantially reduced (see figure 1) and no instances of harm had been identified. As a snapshot, between August and September 2016, more than half of the controlled drug transfers from the assessment unit to other wards were carried out by the ward-based pharmacy technician. The collected data also showed that 50% of patients’ own controlled drug transfers from the acute unit to the wards were undertaken by the pharmacy technician, a significant amount in terms of cost savings and freeing up nursing time. Prior to the pilot, almost 90% of returns had been undertaken by nursing staff and only a proportion of stock had been returned due to lack of time.
No qualitative research was carried out during this pilot; however, feedback was obtained through Trust-wide reports on the positive effect of the presence of pharmacy technicians in the acute unit, as observed by fellow nursing staff.
The pilot proved successful from a staffing perspective. The aim of the pilot was to improve the skills mix between nurses and pharmacy technicians, combining the methodical precise ways of working of the pharmacy technicians with the care-orientated ways of working of the nursing staff. Due to the lack of qualitative research within the pilot, it is not possible to report on patient and staff responses. However, the pilot received positive feedback from the nurses involved in the pilot, as established through their interactions with senior ward managers.
The collected data indicated a reduction in omitted medication incident reports after the pharmacy technician was introduced, which is supported by the literature.4 8 This was achieved through various avenues. The pharmacy technician was able to source medication via routes that may require knowledge of the hospital formulary or even prior knowledge of various routes of requisition, such as the on-call pharmacist. This in turn led to fewer medicines being omitted. Freeing up nurses for other care-related duties during medication rounds was another positive outcome of the trial. This allowed patients to have more nursing contact, which is still a vital part of care, and which patients often miss out on due to the lack of availability caused by understaffing. Nurse-to-patient ratios influence many patient outcomes and not merely the risk of error.9 Administration of the wrong formulation, incorrect storage of medication and administration of contraindicated medications all constituted a significant proportion of reports before the ward-based technicians were in service (figure 1). None of these three errors appeared in any of the reports after the pharmacy technicians were recruited. Ensuring correct formulation and storage and knowing contraindications are significant parts of a pharmacy technician’s day-to-day role. This shows an added benefit to the skills mix in the unit. The pilot also showed that interruptions during the ward round significantly reduced the efficiency of a single nurse (see online Supplementary Table), suggesting that an increase in staff per medication round may act as a buffer.
One cohort study in a busy children’s hospital showed that pharmacy technicians proactively addressed errors or potential errors before proceeding with the intravenous administration process, being more likely to question ambiguity within a chart.8 The primary job of a pharmacy technician is to question ambiguity before supplying medication. The same principle, when applied to medication administration, proves vital in order to minimise harm. The ward currently shows a marked reduction in medication administration incidences, a benefit which the trial has successfully demonstrated.
The major strengths of this pilot are the trial period and the positive responses obtained from both colleagues and the Trust. The staff in the acute unit appreciated the rare commodity of the ward-based pharmacy technicians as they took to the role with openness and creativity. The pilot role became a permanent position within a year, allowing for an extended sample period to ensure that the outcomes of the original pilot had not been random. Thus, the Trust supports the replication of the intervention in different ward settings within its hospitals.
This trial was not without limitations, including the lack of patient satisfaction data before and after the introduction of the pharmacy technicians. The trial introduced an extra layer of patient care, which was enabled by freeing up nursing time. The pilot could have been made more robust by introducing a separate incident reporting system dedicated to the trial, as the under-reporting of incidents is very common. It is important to note that the hospital reporting system has an ‘other’ option, which constitutes the majority of reports. This is another limitation of the trial.
Pharmacy technicians add value to the nursing team by expanding the skill mix and show a reduction in omitted doses. In addition, they help address persistent staffing issues and ensure better use of nursing time.
As a new role, pharmacy technicians will require support with issues that do not directly affect either themselves or the nursing staff. With success, it is easy to overlook the importance of a robust hierarchical system in staff groups that enables employees to form an identity and support networks.
The authors would like to thank Ms Sarah Rice for her help in successfully setting up this pilot. We are grateful to Michelle Rhodes and Dr Neill Hepburn for their contributions and further support with implementing the recommendations and improvements. At a personal level, the authors would like to acknowledge and thank the late David Peters, Senior Clinical Pharmacist, not only for his specialist knowledge, experience and assistance but also for his constant support, kindness, integrity and humanity. This article constitutes part of the doctoral thesis of NE-F within the Doctoral Programme in Pharmacy at Granada University, Spain.
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