Melanie Bond shares her thoughts on cumulative dose check services

We talk to Melanie Bond, E-Prescribing Lead (and Pharmacy Technician) at Lincolnshire Partnership NHS Foundation Trust and a Civica Prescribing user. Civica Prescribing is an Electronic Prescribing and Medicines Administration (ePMA) solution which incorporates the existing Multilex Cumulative Dose Check (CDC) data, which has been designed to reduce the risk of drug overdose at the point of administration. Melanie is providing her views on the experience of using a Cumulative Dose Check capability and from her involvement in helping to inform the development of FDB’s new FHIR / dm+d CDC service.

Hi Mel, can you tell us about some of the challenges you face in prescribing in your trust before you had an eprescribing system installed? 
When prescribers are using paper charts and they are not sure on doses, they would have to rely on the BNF or online BNF to look up regimes.  The pharmacy team later screen the prescription to find out whether the medications are suitable and look at dose ranges and any errors are picked up. Having ePMA takes away that risk, as doctors would be alerted at the point of prescribing via the decision support built into the system which of course saves both time and enhances patient safety.
Another challenge was the missed indications, this can now be mandated in the ePMA system so that all users are aware of the condition the medications are prescribed for. We would also often encounter missed doctors’ signatures on the prescriptions, this would then prevent the nurses from administering that medication until it was signed, causing delays in treatment. The ePMA system now negates that need.

Could you give us an insight into a typical day and ward round that the nursing / clinical team do?
I wouldn’t normally attend the ward round, however during the ward round the clinical team would discuss with patients what medications they are on compared to diagnoses and judge whether medications are working and make any required changes.  

Where does your clinical prescribing system help within this? 
The main benefit is that on ePMA all charts are there electronically. When we used to use paper charts, the doctor would take them into their medication rounds, so nobody had access during this time and there would be delays on all sides. Now, with ePMA, everyone can access the patient record at same time, which is great.  

You and your clinical team administer numerous medications to patients every day – can you tell us what some of the challenges are for the team?  
In the past, when we used paper charts, if a patient was prescribed PRN / as required, the nurses would have to calculate from the chart the minimum interval and the maximum dose i.e., with paracetamol you can only prescribe up to 4g over 24 hours. Nurses would have to manually calculate this and look on the chart to work out whether it was 4 hours since the last dose. They would also have to calculate whether the patient had been given 4g within 24 hours, as it is a rolling 24-hour period - so they would need to work out when the 24-hour period started from. 
However, on ePMA, with cumulative dose checking we have a padlock system. Once paracetamol has been administered to a patient, this is ‘padlocked’ for the next 4 hours, and once the maximum dose has been given for 24 hours, it is padlocked again. This is massively beneficial for several reasons. Firstly, it takes away the manual calculation for nurses. Secondly, it is particularly beneficial for patient safety. With the potential distractions on mental health wards, it means that mistakes cannot be made in this area, when the padlock is on. In addition, it is a visual aid for patients, and nurses have fed back that it is beneficial that they can show patients the padlock and demonstrate that they cannot give the patient the dose at that time. 

Can you tell us about how frequently you saw this problem occurring?  
We literally saw this all day, every day. This takes away the calculation, making it safer for patients, and there are not going to be overdoses. 

What ideally would you want your prescribing and administration system to check against?  
We would want to calculate across different routes, for example whether oral or IV. We’d also like to be able to calculate dose across forms as well as for PRN and regular medications. If you have the same regular medication and ‘as required’ - as you frequently do in mental health – we would want to be able to check that. 

You’ve been involved with the clinical forum with FDB haven’t you?  How have you found working with us on this development?  
FDB’s clinical forum has been great. If the team does not understand something, they will ask me about it. They take everything on board and ask for more information if needed. We have different trusts:  mental health trusts, acute trusts etc and they take on board all the scenarios we have. They are helpful, knowledgeable and everything they send back is informative. I could not ask for anything more! 

What are the benefits of the new type of service for users?  If so, what are these? 
The benefits of the new FDB CDC service include the provision of checking CDC administrations across different routes and preventing the need for manual calculation by nurses and the subsequent enhanced patient safety.  

What would be the next phase of development that you’d be keen to see (which would make a difference in clinical safety and supporting prescribing and administering teams?) 
The next thing we’d really like to see is developments around high dose anti-psychotic medications. Our patients have T2 and T3 documents – legal documents stating what medications our patients can take.  If the doctor prescribes a medication that is NOT in the T2 or T3 it will flag up that it is not on the legal document and would let the doctor know. With high dose anti-psychotic medications, we have limits – allowed up to 100% of BNF. Once over the maximum, the system would alert the doctor so that a high dose antipsychotic form could be completed to continue treatment. We would want the system to check individual medications and state what level we are at – say 50% or 75%. 

There’s a lot of talk currently about FHIR and dm+d compliance - do you have any thoughts on this? 
ePMA must be dm+d compliant by 2023, so dm+d compliance by then is essential. We would rely on FDB to make any changes that are required and will look forward to this being rolled out. In terms of interoperability, we use ePMA as a standalone, but in the future, we would look at integration with other systems, so this is important to us as well.