Vulnerable populations are vulnerable because they are susceptible to
harm in health care environments. It is important that the healthcare
issues specific to the population with learning/intellectual disabilities
are considered when prescribing and deprescribing.
Deprescribing tools must be validated in the population with
learning/intellectual disabilities to ensure safety and quality care.
People with learn...
Vulnerable populations are vulnerable because they are susceptible to
harm in health care environments. It is important that the healthcare
issues specific to the population with learning/intellectual disabilities
are considered when prescribing and deprescribing.
Deprescribing tools must be validated in the population with
learning/intellectual disabilities to ensure safety and quality care.
People with learning/intellectual disabilities and behaviour disorders
provide particular challenges.
In the population with learning/intellectual disabilities compared
to the general population, the multi-morbidity burden is greater, occurs
at much earlier age, and the profile of health conditions differs [1].
People with learning/intellectual disabilities use multiple
medications and may have been taking them for many years. Extreme care in
required when de- prescribing many medications in this population group.
The principles of good de-prescribing during medication review in the
population with learning/intellectual disabilities, based on the British
Pharmacological Society's Principles for Good Prescribing 2010, provide a
template for quality de-prescribing in this population group.
Principles of Good De-prescribing during Medication Review in the
Population with Learning/Intellectual Disabilities (and Behaviour
Disorders). Based on the British Pharmacological Society's Principles for
Good Prescribing 2010
1. Be clear about the reasons for de-prescribing.
2. Take into account the patient with learning/intellectual disabilities
and behaviour disorders medication history before de-prescribing.
3. Take into account other factors that might alter the benefits and risks
of de-prescribing treatment in the patient with learning/intellectual
disability and behaviour disorders.
4. Take into account the patient's/carer's/families/advocates ideas,
concerns, and expectations.
5. Ensure all medicines are effective, safe, cost-effective in appropriate
form individualised for the patient with learning/intellectual disability,
behaviour disorders and other conditions such as dysphagia, autism.
6. Adhere to national guidelines and local formularies where appropriate.
Use caution where the population with learning/intellectual disability
have not been considered in the guideline development process.
7. Write unambiguous correct documentation detailing reason for de-
prescribing.
8. Monitor the beneficial and adverse effects of de-prescribing medicines
and any effects on behaviour.
9. Communicate and document all de-prescribing decisions and the reasons
for them such as transferred to appropriate personnel such as GP,
pharmacist, psychiatrist, epileptologist, carer and patient.
10. De - prescribe within the limitations of your knowledge, skills and
experience of the population with learning/intellectual disabilities and
behaviour disorders.
1. Cooper S-A, McLean G, Guthrie B, et al. Multiple physical and
mental health comorbidity in adults with intellectual disabilities:
population-based cross-sectional analysis. BMC Family Practice.
2015;16:110. doi:10.1186/s12875-015-0329-3.
Wright and colleagues report on a single centre survey of inpatient
perceptions and experiences of the current discharge process, and identify
improvement opportunities in relation to waiting for medicines, and lack
of counselling by pharmacists.(1) Problems such as low awareness among
inpatients of pharmacy services, or pharmacists citing challenges to
achieving patient medication counselling have b...
Wright and colleagues report on a single centre survey of inpatient
perceptions and experiences of the current discharge process, and identify
improvement opportunities in relation to waiting for medicines, and lack
of counselling by pharmacists.(1) Problems such as low awareness among
inpatients of pharmacy services, or pharmacists citing challenges to
achieving patient medication counselling have been reported
internationally.(2,3)
In summer 2015 we undertook a similar small survey (building on our
previous work from 20124) at our 600 bedded teaching hospital. A Patient
Ambassador approached 33 patients (22 aged over 60 years) to ask questions
about their knowledge of their medicines. Thirty (90%) patients were
taking regular medicines prior to admission. Of these 30, 22 patients
recognised that their existing medicines had been changed whilst in
hospital, one did not know, and 7 claimed that there had been no changes.
Seventeen (77%) of the 22 patients reported that medication changes had
been explained to them, though in only 2 instances did the patient
acknowledge that the pharmacist undertook this counselling. Of the 26
patients commenced on new medicines during their stay only 6 (23%)
received information on side effects. Despite this, 18 of all 33
participants indicated that they received enough information about their
medication during their stay, though only 3 of these patients responded
that this information had been provided by the pharmacist.
Wright et al quite correctly reference the importance attached to the
National NHS Inpatient Survey which assesses patient experience at
hospitals across England, and results from the medicines related questions
section of this survey form part of the Hospital Pharmacy and Medicines
Optimisation project. They also argue for the development of a new model
of care for patient discharge. As an enhancement to discharge medicines
counselling provided by pharmacy, we are utilising a checklist for nursing
staff to follow when discharging patients which requires the nurse to
explain the medication and side effects. We have also very recently moved
from a faxing system to an electronic referral system (Pharmoutcomes) for
sending critical clinical information to a patient's regular community
pharmacy to enable the community pharmacist to offer on-going support and
advice on medication-related issue that may have arisen during the
admission.
Ensuring that all hospital processes around discharge and all
hospital staff involved with the discharge process are aligned with such a
new model of care for patient discharge may benefit from adopting the
Always Event approach.(5)
Yours sincerely
Mike Wilcock
Sally Miles
Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall
REFERENCES
1. Wright S, Charles W, Morecroft CW, Mullen R, Ewing AB. UK hospital
patient discharge: the patient perspective. Eur J Hosp Pharm
doi:10.1136/ejhpharm-2016-001134
2.King PK, Martin SJ, Betka EM. Patient awareness and expectations of
pharmacist services during hospital stay. J Pharm Pract 2016 Aug 31. pii:
0897190016665541
3. Chevalier BA, Watson BM, Barras MA, Cottrell WN. Hospital pharmacists'
perceptions of medication counseling: A focus group study. Res Social Adm
Pharm. 2016 Sep-Oct;12(5):756-71.
4. Wilcock M, Lawrence J. Patients' experience of the hospital pharmacy
team - still further work to be done! Pharmacy Management 2015;31(1):15-
20.
5. NHS England. Always event (cited 18 January 2017)
https://www.england.nhs.uk/ourwork/pe/always-events/
We read Clayton's report published in the BMJ with great interest.
Clayton and his team's quality improvement project demonstrated how the
use of symbols and pictures at Lahore, Pakistan, help increase patient
adherence.
The International Pharmaceutical Federation (FIP) and the Children's
Hospital of Eastern Ontario (CHEO) research group have been studying the
use of pictograms for many...
We read Clayton's report published in the BMJ with great interest.
Clayton and his team's quality improvement project demonstrated how the
use of symbols and pictures at Lahore, Pakistan, help increase patient
adherence.
The International Pharmaceutical Federation (FIP) and the Children's
Hospital of Eastern Ontario (CHEO) research group have been studying the
use of pictograms for many years. We agree with the author regarding the
use of pictures as a supplemental aid to verbal and written directions to
enhance patient understanding of medication regimens. However, it is
important to state that there are other factors affecting the
interpretation and preference of pictograms that must be considered. These
factors are: culture-specific pictograms, provision of verbal
instructions, and education levels.
Culture influences the comprehension and acceptability of pictograms.
Our previous publications include focus group discussions, structured
guessibility interviews and an online survey, which all indicate the need
for culture-specific pictograms to maximize the effectiveness of health
information communication.(1,2,3) A First Nations focus group, built of
community members and health care professionals, discussed pictogram
modifications to reduce interpretation errors based on cultural
characteristics.(1) A consensus was made to include additional components
to pictograms relating to food, alcohol and time of day at which the drug
is administered.(1) Subsequently, we conducted another study evaluating
pictogram interpretation in non-European cultures (Chinese, Somali, East
Indian). A notable difference was shown in the distribution of
interpretation errors amongst these cultures, specifically for route of
administration and auxiliary instruction pictograms.(2) Lastly, we created
an online survey to asses the preference between multiple pictograms
representing distinct medical instructions in populations worldwide:
Africa, Asia, Europe, Latin America, Northern America, and Oceania.(3)
Differences in pictogram preference arose between the different world
regions.(3) Based on the assessments of these publications, we can
conclude that culture-specific pictograms are necessary to assure proper
understanding of medical instructions in target populations.
Furthermore, another study conducted at our hospital analyzed the
extent that education level affects the preference and interpretation of
pictograms.(4) A significant difference in image preference was observed
between participants of various education levels.(4) Also, the study
analyzing pictogram interpretation in non-European cultures demonstrated a
strong correlation between the individual's level of education and their
ability to accurately interpret a pictogram.(2) The greatest difference
was found between patients with no formal schooling and those with a
minimum of an elementary level education.(2) Overall, the levels of formal
education significantly affect the interpretation, comprehension, and
preference of medication pictograms.
As mentioned in Clayton's report, pictures should be used in
conjunction to written or spoken words. Such action will increase
attention and recall of medication instructions, resulting in better
patient adherence. According to the FIP guidelines for the labels of
prescribed medicines, the use of pictures to convey medical directives
should not be used single-handedly and should always be combined with
written instructions.(5) In order to enhance patient understanding and
adherence to medical directives, the use of pictograms as a supplemental
aid to verbal and written directions should not be underestimated.
We encourage you to visit the FIP website for more information on
pictograms (http://www.fip.org/pictograms). A pictogram software, entitled
The Prescription Architect (Beta Version), is now available as a tool for
practice.
References
1. Grenier, S., Vaillancourt, R.,Pynn, D., et al. Design and
development of culture-specific pictograms for the labelling of medication
for first nation communities. Journal of Communication in Healthcare.
2011;4(4): doi: 10.1179/1753807611Y.0000000007
2. Kassam, R., Vaillancourt, R., Collins, J.B. Pictographic
instructions for medications: do different cultures interpret them
accurately? International Journal of Pharmacy Practice. 2004:12;199-209:
doi: 10.1211/0022357044698
3. Wilson, E. Vaillancourt, R., Pascuet, E., et al. Seeking
international consensus in the use of icons for medication instructions.
4.Richler, M., Vaillancourt, R., Celetti, S.J., et al. The use of
pictograms to convey health information regarding side effects and/or
indications of medications. Journal of Communication in Healthcare.
2012;0(0):doi:10.1179/1753807612Y.0000000012
5. International Pharmaceutical Federation. FIP Guidelines for the
labels of prescribed medicines. The Hage, The Netherlands. 2001. Available
from: http://www.fip.org/www/uploads/database_file.php?id=256&table_id.
Conflict of Interest:
Dr. Regis Vaillancourt is responsible for the FIP Pictogram Project.
No other competing interests.
Well done folks!
We do not have a formalized A4 type of paper to fill up prior to the procedure, but we carry out most of these checks without ticking boxes. We have a pathway, which includes almost all of these and is normally checked by the Endoscopy nurse and a cancer specialist nurse. Only an independent bronchoscopist (not the trainee) is allowed to check the safety prior to add the patient in the list for the procedure.
I...
Well done folks!
We do not have a formalized A4 type of paper to fill up prior to the procedure, but we carry out most of these checks without ticking boxes. We have a pathway, which includes almost all of these and is normally checked by the Endoscopy nurse and a cancer specialist nurse. Only an independent bronchoscopist (not the trainee) is allowed to check the safety prior to add the patient in the list for the procedure.
I highly respect and appreciate your hard work to formalize this for the safety of the patient.
I would suggest you to check the patients ECG prior to the procedure (most them are middle aged and elderly population). I had been doing this for almost 15 years and unfortunately had encountered various ECG abnormalities which led to postponed the procedures. These were Complete and second degree heart blocks, unexplained bradycardia, various tacchyarrythmias and ischemic changes. Many of them were symptomatic for it's isolated reason, which could have easily been missed, if the ECG were not performed, due to their underlying illness mainly malignancy. If not wrong, I might have stopped some problem.
I thought that this would be helpful.
Once again, well done everybody.
As a result of this quality improvement project we have changed the
adult fluid prescription used within the Trust. We have redesigned the
prescription section to have a clearer space to document patient related
cautions, such as heart failure; and included a printed prompt for
'Indication' on each prescriptions line.
Discharge summaries are an important connection between care in
hospital and primary care, and effective transfer of information is vital
for patient safety and continuity of care. Having spent my foundation
year one in hospital and now working in a general practice, I have been
able to see discharge summaries from both sides. Discharge summaries
contribute significantly to the work load of junior doctors and often
re...
Discharge summaries are an important connection between care in
hospital and primary care, and effective transfer of information is vital
for patient safety and continuity of care. Having spent my foundation
year one in hospital and now working in a general practice, I have been
able to see discharge summaries from both sides. Discharge summaries
contribute significantly to the work load of junior doctors and often
require long periods spent in front of a computer away from patients. The
quality of these summaries often varies between doctors but also depending
upon how much time the author can set aside for writing the summaries.
Any proformas or teaching to help juniors at this important task is
welcome.
It is unfortunate that the teaching interventions here did not show
improved discharge summaries and I wonder how the foundation year one
doctors would reflect on this teaching later in the year? It is
interesting that the foundation year two doctors seemed more reluctant to
consider that they could improve their discharge summary writing, so
perhaps establishing attitudes earlier in a trainee's career is an
important step. Maybe writing discharge summaries is a skill which could
be introduced to final year medical students? I look forward to reading
about future developments with this project.
Vulnerable populations are vulnerable because they are susceptible to harm in health care environments. It is important that the healthcare issues specific to the population with learning/intellectual disabilities are considered when prescribing and deprescribing.
Deprescribing tools must be validated in the population with learning/intellectual disabilities to ensure safety and quality care. People with learn...
Dear Editor
Wright and colleagues report on a single centre survey of inpatient perceptions and experiences of the current discharge process, and identify improvement opportunities in relation to waiting for medicines, and lack of counselling by pharmacists.(1) Problems such as low awareness among inpatients of pharmacy services, or pharmacists citing challenges to achieving patient medication counselling have b...
Dear Editor:
We read Clayton's report published in the BMJ with great interest. Clayton and his team's quality improvement project demonstrated how the use of symbols and pictures at Lahore, Pakistan, help increase patient adherence.
The International Pharmaceutical Federation (FIP) and the Children's Hospital of Eastern Ontario (CHEO) research group have been studying the use of pictograms for many...
As a result of this quality improvement project we have changed the adult fluid prescription used within the Trust. We have redesigned the prescription section to have a clearer space to document patient related cautions, such as heart failure; and included a printed prompt for 'Indication' on each prescriptions line.
Conflict of Interest:
None declared
Discharge summaries are an important connection between care in hospital and primary care, and effective transfer of information is vital for patient safety and continuity of care. Having spent my foundation year one in hospital and now working in a general practice, I have been able to see discharge summaries from both sides. Discharge summaries contribute significantly to the work load of junior doctors and often re...
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