July02, 2022,UK

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Abstract Volume: 4 Issue: 4 ISSN:

Prescribing Psychotropic Medications at Kuwait Centre for Mental Health (kcmh)- Clinical Audit.

Mohamed Binali1, Hammad Mahmoud*, Mohamed Zain2, Tarek Shoukry3Mohamed Abuzaid4.

  1. specialist in psychiatry, sleep disorder unit ' Kuwait Center for Mental Health (KCMH), Kuwait state
  2. Sineor pharmacist at KCMH, Kuwait State
  3. Consultant psychiatrist Kuwait Center for Mental health (KCMH) Kuwait State.
  4. Consultant psychiatrist KCMH, Kuwait State
     

Corresponding Author: Hammad Mahmoud, Psychiatry fellowship doctor, CNTW foundation NHS Trust UK.

Copy Right: © 2022 Hammad Mahmoud, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Received Date: March 15, 2022

Published Date: April 01, 2022

Prescribing Psychotropic Medications at Kuwait Centre for Mental Health (kcmh)- Clinical Audit.

Introduction

This is a retrospective study, a clinical audit for prescribing the medication chart  of inpatient at Kuwait Center for Mental Health( KCMH)  during the past 3 months from 1st May 2021 till 30th July 2021.

It is the first clinical audit to be done according to our knowledge that follows a good practice guideline for prescribing and managing medications according to gold standard guidelines such as NICE and GMC guidelines.

With no previous clinical audit done at KCMH and aiming to establish an adequate on-going service for monitoring and prescribing within a clear standard protocol for the present state and future computer produced charts.

Do no harm for patients (primum non nocere), a concept given by Hippocrates that was an important factor in the good and safe practice. 

When prescribing psychotropic medications to our inpatients, there are several points should be taken into considerations: 

1. When writing the prescription, reviewing the patient to assess for affect, side effects and need to continue or discontinue.

2. Evidence based showed medications prescribing must have: an evidence-based prescribing, drug interactions and sensitivity, adverse effects, checking dosages, prescribing within limits of competence, using prescribing formularies, update and following clinical guidelines and responsible delegation for prescribing administration and dispensing.

3. At Kuwait Centre for Mental Health, all inpatients’ prescriptions are written by handwriting process, without computer produced prescription system available at the present time.

4. Aiming to improve our service safety, efficiency, and convenience, it is an important to follow international standard guidelines recommendations.

5. This audit will not address the treatment adherence, side effects and concordance but it shows the concerns and difficulties with prescribing, writing and filling the medications chart according to standard guideline including as required and reconciliation list.


Our Standard: 

Keeping up to date and following clinical guidelines from national institute for health and care excellence (NICE), British National Formula (BNF), General Medical Council (GMC) as golden standard and also follow the local prescribing guidelines from Ministry of Health (MOH) at State of Kuwait.


Methods

1. Population: our sample population were 188 patients admitted to KCMH during period of 3 months who has diagnosis of mental illness according to DSM V criteria. 

2. It was collected from all acute adult admission, forensic, child and adolescent and old age wards.

3. They were males and females with age range from 13 years -70 years old.

4. There were three researchers: one pharmacist, and two psychiatrists who collected data and were not involve in the patients care plan.

5. The collected 188 sample were recorded   from 1st May 2021 till 30th July 2021.  The process started on 1st November 2021 and ended on 30th January 2022, it took about 3 months, and it was done in File dept. (at KCMH) all the time to ensure confidentiality.

6. The sample was belonged to 188 inpatient medications chart after excluding 5 DAMA charts due to lack of information’s and did not fil the criteria of the research. All the charts were prescribed by their treating doctor.

7. The sample was collected and recorded by using our assessment tool (appendix 1), mainly looking at inpatient file that include prescribing chart, present and previous reconciliations list included.

8. The collected forms presented old and new medication charts, old and new reconciliation charts.

9. The assessment tool (appendix 1) include: prescribing and administration of inpatient medication chart. It contains screening questioners for patient data such as full name, demographic data, diagnosis, age, date of admission, ward and hospital number, doctor signature, date, time, written in capital letters, dose in metric units, written in ink, clear and a readable, state the dose, route of administrations, allergies, rewrite, as required medication (min. and max dose, indications, cancel after 2 weeks).

10. Also   medication reconciliation list was reviewed and recorded (developed by our pharmacy sector), included the date, the list of medication on discharge and the pharmacy signature.


Results

All 188 charts and clinical notes for each patient were reviewed and documented.

The outcome showed:

A.  There were less than 150 reconciliations charts which being unable to allocate in the file or missing from the patients’ files.

B.  All data were analyzed using SPSS ver. 26, using descriptive approach looking at the number and the percentage of each criterion in our Audit tool.

C. It showed the following:
 

Discussion

The Audit results draw an important massage: with the   increased number of patients in the community admitted to KCMH (only psychiatric facility available in the state of Kuwait) and on the long term, there will not be a placement to accommodate all patients.  It is a burden on the government and it’s not a cost-effective service.

From 188 charts, there were 5 charts excluded because they did not fill   the criteria of the audit research such as being as inpatient for less than 72 hours, no regular medications were prescribed and discharge against medica advice.

There were less than 150 medication reconciliation list on discharge because some list were not found in the files, missing and almost all of them lacking pharmacist signature indicating poor practice and management for patient safety.


The above results showed:

  • It is clear the writing of the patient’s full name is an issue that can be resolved immedility to avoid any conflict.
  • Some charts lack diagnosis because it was missed or not included from the beginning. This issue can be resolved after finalizing the diagnosis on discharge.
  • Regarding treating doctor signature, it should be always presented in the medication charts as a good practice. The stamp is not enough.
  • Writing medications doses in decimal units is a bad practice, It could be avoided and the metric dose should always be written for all medications listed on the chart.
  • Most of the medications written on the prescribing charts presented in this audit were not dated. This showed the lack of awareness, and it should be address immediately.
  • The route of medication administration was missed in 35% indicating lack of awareness and safety concerns. It is very important issue to mention in the guideline to avoid further crises.
  • There is lack of awareness for the importance of recording allergies and sensitives with 87% of charts is not written. It is emphasizing the importance of recording the patient history of allergies and sensitives to ensure safety and good practice.
  • For rewrite prescription including doctor signature and dated, more awareness about recording all details that are needed in the chart.
  • For as required medications, it is reported inadequately and showed lack of awareness and importance of following guidelines to ensure good practice, efficacy and management.
  • For reconciliation section, it is clear not all wards using the new form, missing from the patients file on discharge and lack of pharmacist signature which can be address and improvement.
  • Health care professional need more training and awareness about the above results drawn from the audit to improve safety and management of inpatient service.
  • Difficulties that were experience during the Audit process: A. the time spent to find and allocate patients prescription. B. the Time to allocate patients files C. Poor Clinical notes arrangement D. Unable to find the reconciliation list. E. using different medications charts style and reconciliation forms.

 

Conclusion & Recommendations

  • It is time to change our practice.
  • With better documentation, training requirement and change in practice to ensure safety and efficacy.
  • All doctors should follow the guidelines to ensure good practice in prescribing medications.
  • This audit will reaudit in 6-12 months.
  • We aim for our results to be introduced in a realistic and achievable way and to look at the reasons behind that and implant a clear action plan.
  • In this Audit, personal details were well documented but s lack few datils such asFull name and diagnosis are important, The route of administration , date and signature are important to documented.
  • For PRN section that include indications, mini and max dose were not documented. PRN was not discontinued if not used in 2 weeks.
  • For reconciliation, there are no pharmacist signature and old form was used on regular basis.
  • With clear quality improvement plan that is a fundamental part of an audit I, t should identify the individual responsible for each action with date of next re audit.

Reference

1. https:// www.nice.org.uk: medicines guidelines and prescribing support from NICE.

2. BNF 2020- NICE evidence service.

3. Cushing A, Metcalfe R; Optimizing medicine management: from compliance to concordance 2007 Dec 3, page: 1047-1058.

4. Audit Commission. A spoonful of sugar: medicines management in NHS hospitals by: Audit Commission; 2001.

5.  British National Formulary. www.bnf.org/bnf/

6. Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance.  Health Care 2002; 11(4):340–4.

7. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002;359(9315):1373–8.

8. Department of Health. Building a safer NHS for patients: Implementing an organization with a memory. London: Department of Health; 2001.

9.  Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995;274(1):35–43.

10. Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997; 277(4):312–7.

11. National Patient Safety Agency. Quarterly national reporting and learning system data summary autumn 2006. London: NPSA; 2006.

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