Medication Safety: Putting the Patient First

Medication Safety: Putting the Patient First

Join us for a series of blog posts surrounding the 2022 World Patient Safety Day theme of Medication Safety. In this post, Paediatric Surgery Registrar and 2020-2021 RCSEd Scottish Clinical Leadership Fellow Miss Sesi Hotonu looks at why the patient should be put first when it comes to medication safety.  

Patient safety is at the heart of everything we do as surgeons. An important part of our practice is medication safety, which is also the theme of World Patient Safety Day 2022. Polypharmacy can be difficult for patients or their carers to manage, so we must remain mindful of the practicalities of taking multiple medications when initiating or continuing treatment. Edith and Jane share their experiences of managing multiple medications at home.

Edith's Story

Edith is 71 years old, and has lived in the Scottish borders all her life. She left school after her A levels, and worked a busy job in the advertising department of a local newspaper until her retirement 10 years ago. Outside work, she was active and sporty, teaching swimming locally. She is married, and has no children. She is however surrounded by her adoring extended family, and is honorary grandmother to her sister’s grandchildren.

Edith has a kidney transplant, which was performed 10 years ago. Despite being very healthy most of her life, her GP repeatedly noted her to have mild renal impairment, the cause for which could not be identified. She developed significant worsening of her renal function following a trip to Malta: salmonella food poisoning contracted whilst on holiday led to an admission to the Royal Victoria Infirmary in Newcastle upon Tyne. Her renal function continued to deteriorate on discharge from hospital, until it reached a point where she was placed on the renal transplant list with dialysis recommended while she awaited transplant. She was, however, fortunate to receive a kidney transplant two months after being placed on the list, managing to avoid dialysis in the process. Her surgical recovery was uneventful.

In the 10 years since her operation, Edith’s health has remained stable through a daily medication regime. Apart from immunosuppressant medications for her transplant, she also takes tablets for angina, hypertension and arthritis – a total of 11 medications, taken once daily. She manages this through a pill box that she makes up herself. She receives a monthly supply from her chemist, which she can order through an app on her phone.

Managing changes to her medication is relatively easy, as her renal consultant is extremely vigilant in optimising Edith’s health, initiating changes that fit smoothly with Edith’s lifestyle. Edith feels particularly fortunate to have easy access to her consultant – any issues can be communicated by email and are quickly resolved. This has been the experience of the other patients in the local renal support group that Edith attends, as they have all commented on the ease with which their responsible consultant can be contacted, and how medication issues are efficiently and rapidly resolved. She recalls a recent episode when she needed her angina medication adjusted and her enquiry was dealt with very efficiently. Her experience is unfortunately, however, not the same for all patients with polypharmacy. She is aware that either through difficulties with communication, personal or mental health, some patients can struggle to contact their responsible clinicians or manage their medications themselves.

Nancy's Story

Jane is 62, and is a retired teacher. She and her two siblings care for their mother Nancy, who is 91. Nancy has advanced dementia, and lives alone in a small bungalow with the support of her children and carers who visit three times a day. During her working life, Nancy was a school teacher with a university level education. Jane and her siblings are all retired, but used to work demanding professional jobs.

Jane recalls her mother as being a fiercely independent, intelligent and capable woman. She was always a little more fragile physically than Jane’s father, however only developed significant health problems later in life. By age 60, Nancy was being treated for arthritis and hypertension. She, however, continued to be active in her community through charity work and art, and was a doting grandmother with an active social life.

Nancy’s cognitive decline began in her early 80s. Jane remembers a few instances were Nancy seemed repetitive and a little forgetful. She was able to hide this well however due to her sharp wit. A significant decline occurred 4 years ago, when Jane’s father became very ill. Whilst he was in hospital, it became clear that Nancy was struggling to manage at home and needed her children to remind her why her husband was in hospital, and give details surrounding his admission. When Jane’s father died a few months later, Nancy’s cognitive ability declined sharply. The grief she was experiencing and the change to her routine with her husband gone made her memory so poor she was unable to cope independently. This included managing the multiple medications she takes daily.

Nancy’s health problems include arthritis, hypertension, hypothyroidism, peripheral oedema secondary to heart failure and leg ulcers. She suffers with back pain, and has two joint replacements. She takes 8 medications daily, with occasional steroid injections for her painful joints. Jane and her siblings work hard to ensure that Nancy can continue to live in her own home. They have taken over the management of Nancy’s health and medications, including ensuring supply and safe administration. Nancy has had daily carers since her husband’s death, and her children take it in turns to visit from around the country every 3 days. Caring for Nancy has been a steep learning curve, and has at times been difficult. Her children are however pleased that they have reached a point where Nancy is safe, happy and well cared for despite her significant memory problems. They are particularly grateful to Nancy’s carers, who have been consistently kind, considerate and compassionate.

Nancy’s medications are supplied monthly from her local pharmacy who have served the family for many years. The pharmacy has been very accommodating and supportive. One of Nancy’s children usually calls and orders her prescriptions, which are delivered to Nancy’s house every month. Each week, they dispense the medications into a large, easy to open Dosette box labelled clearly with the days of the week. Fortunately, all her medications are taken once a day, in the morning. Jane calls her mother every morning to remind her to take her medications. Nancy’s children have found that this system works best for her multiple medications, as her carers are not allowed to administer medications that are not in a sealed pharmacy box. This system also allows them to track the supply of their mother’s medications and order new ones as needed, a service the care company does not provide.

Jane feels the key to their medication management success is being organised and anticipating needs. This can, however, become difficult when short term medication changes occur, such as when Nancy required a week’s course of antibiotics for an infected leg ulcer which she needed to take 4 times a day. They had to increase the frequency of calls and visits, and place multiple reminders around the house – this proved quite stressful. Another tricky situation occurred when there was an increase in the dose of one of her medications, which caused the delivery of medicines to fall out of sync. Despite the support of the pharmacy, Nancy’s children had to adjust their visits to coincide with medication deliveries. Nancy’s children are all retired, however they live 2 hours or more from their mother, and have children and grandchildren of their own to support. Jane believes that they would not be able to manage their mother’s care if they were still in full-time employment.

Due to her significant cognitive impairment, Nancy’s children have power of attorney for her health and finances. This means that health professionals are able to discuss aspects of her care with Jane and her siblings. This is particularly important, as Nancy cannot recall details of hospital and GP appointments or communicate important changes to her medications or healthcare to her children. Jane and her siblings have found it difficult to contact Nancy’s GP and other health professionals on occasion to discuss concerns, especially with the increased pressure on the health service that the coronavirus pandemic has caused. They feel fortunate to have several medical professionals in the family who have been able to give advice on engaging with the health service. Jane feels that the most important aspect of her mother’s care is an understanding of the daily challenges of a patient with cognitive decline by health professionals, and is especially grateful for clinical encounters where her mother has been treated with sensitivity and compassion.

Despite her many medications, Edith feels that they are manageable through the excellent communication and explanations from her renal consultant. Her biggest advice for clinician’s compliance is to be good communicators: compliance with medication and other health interventions is best achieved through exploring an individual patient’s social situation and tailoring care around their unique circumstances. She would also encourage patients and their carers to be bold in asking questions about their medications, and to work with clinicians to devise management options that best suit their lifestyle. Jane also believes that good communication is key, especially with patients with advanced dementia like her mother. Important information should be given in a timely manner to the family and carers, and the patient treated with sensitivity and compassion. People with cognitive decline are extremely vulnerable, and coordinating their care must be done with an appreciation of the practicalities of their daily life and the impact on their carers. Jane’s biggest advice for health care professionals is to perform regular medication reviews so that, where possible, medications can be stopped, or their timings, doses or routes amended to make administration as simple and safe as possible for vulnerable patients.

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