Dustpan & brush sweeping up pills

Emergency Care

How can Emergency Departments deal with medication transfer & waste?

The work described here won the UKCPA Best Pre-registration Pharmacist Poster award at the Pharmacy Together 2019 conference.

Growing financial pressure on the NHS has led to increased scrutiny of high cost areas such as medicines expenditure. Within the Emergency Department at Wrexham Maelor, it is recognised that medication is often not transferred with patients to downstream wards or on discharge. Consequently, ‘lost’ medications are omitted and re-dispensed. This compromises patient safety and satisfaction, with additional cost implications to the NHS

The objective of this audit was to assess medication transfer and wastage within the Emergency Department, with a standard set of 100 percent of Emergency Department ordered medication to be transferred with patients to downstream wards or their Emergency Department lockers. The 100 percent standard was set in order to comply with Betsi Cadwaladr University’s mandatory Emergency Department transfer checklist. 

A five-week pilot assessed the feasibility of the audit and tested the data collection form. Following minor amendments, data was collected for 12 weeks from December 2018 to February 2019. 

Daily Emergency Department locker checks identified medication which had not been transferred with patients, who were traced using the hospital’s electronic patient record. Medication was then reunited with patients on downstream wards. If discharged, patient’s own drugs were destroyed and ordered medication was returned to stock. The audit excluded medication of deceased patients.

In an increasingly austere environment with an escalating patient burden, this is a key area for further investigation and improvement.

The number of Emergency Department ordered medications was recorded daily. The standard was calculated by taking the number of ordered medicines not transferred and dividing by the total number of ordered medicines.

Medication not transferred was assessed using the NPSA risk assessment tool. ‘Red’ critical medication had their corresponding prescription charts reviewed to identify omitted doses (not given by time of next scheduled dose). This excluded stopped or withheld medication. Results were verified by the Emergency Department pharmacist. Cost analysis for all patient’s own drugs was calculated using the Drug Tariff.

During the audit period we found that 317 medications were ordered by the Emergency Department. Around half (49%; n=155) of these were transferred with patients and the rest (51%; n=162) remained on the Emergency Department. 

A total of 22 ‘red’ critical medicines were not transferred, nine of which were subsequently omitted. Examples included filgrastim, anticoagulants and sodium valproate. 

A total of 627 patient’s own drugs were found on the Emergency Department. The cost of the destruction of these totalled £2205.83. However, a sum of £1905.16 was saved as a result of auditors tracing and transferring medication to admitted patients. A high proportion of ‘lost’ medication was subsequently re-dispensed by pharmacy. On observation, controlled drugs storage was a concern with safe custody and recording requirements not being consistently met.

The audit standard was not achieved; however, results may have been influenced by the lengthy dispensary turnaround time and winter pressures. Failure to administer ‘red’ critical medicines can significantly impact patients, including prolonging hospital stay and catastrophic results. In an increasingly austere environment with an escalating patient burden, this is a key area for further investigation and improvement. 

Significant cost savings could be made by improving medicines management in the busy Emergency Department environment. Expansion of the Emergency Department pharmacy service could facilitate cost-effective medicines management, adherence to controlled drug legislation and improved patient safety.


This work was presented as a poster at the Pharmacy Together 2019 conference, organised by UKCPA and Pharmacy Management.

Additional authors:

Sheila Doyle, Betsi Cadwaladr University (BCU) Health Board, Wrexham

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest zstatement: 

The author declares: support from Wrexham Maelor Hospital (Betsi Cadwaladr University Health Board) for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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