Procedimientos

More recently, The King’s Fund offered a definition that linked medicines management to safety with an additional focus on value for money and an enhanced use of medicines by patients, thereby introducing the idea that patients themselves have a role in managing their medicines:

“Medicines management supports better and more cost-effective prescribing in primary care, as well as helping patients to manage medications better. Good medicines management can help to reduce the likelihood of medication errors and hence patient harm.”^60(p10)

However, relatively simple definitions of medicines management, such as the ones above, do not communicate the complicated, multi-professional, dynamic system that comprises different types of patients interacting with different healthcare professionals – doctors, pharmacists, health visitors, nurses –

working across different sites and settings who adopt varying roles in supplying, monitoring and reviewing medicines. The healthcare professionals involved work for different organisations and belong to different professional groups with diverse proprietary processes, procedures, discourses and professional

jurisdictions, norms and prejudices. Within this complicated environment patients who receive multiple medicines, who are often chronically ill and have multiple co-morbidities, will often self-manage their day-to-day medicines. As such, it is a complex system – one in which there are many interrelated

components that impact on each other but cannot be explored in isolation;⁶² and one that varies in different care settings – for example in the community and in hospitals – and for different medicines.

1.2.1 Medicines management models

As discussed, systems of medicines management are complex and so to better understand how they operate in different settings and to impose some

standardisation, a number of models have been developed to describe and map their processes.

Avery et al. adopted a systems approach to explore medicines management but with a focus on the primary care system to identify the risks in the system that can produce adverse events.⁶³ Stages in this model were prescribing,

dispensing, monitoring and review, and patient education and compliance.

Systems failures included deficiencies in computerised warning systems,

13

inadequate inter-organisation communication, poor therapeutic knowledge dissemination, poor systems for repeat prescribing, organisation and training of staff and deficiencies in HCP-patient communication. They listed possible proximal causes of an adverse event including lack of medicines knowledge, slips and memory lapses. Figure 2 is the Avery et al. adaptation of Reason’s

‘swiss cheese’ model describing risks in medicines management using the scenario of a patient request for a repeat prescription of a previously used medicines which is contra-indicated – it demonstrates how a specific risk in the system can penetrate multiple layers or barriers designed to prevent it.⁶³

Building on this model, there is an opportunity to enhance the role the patient plays as a system barrier to create more resilience in the system. For example, enhanced patient knowledge of their medicines – those that are current and discontinued – may avoid the repeat prescription request and patients creating their own checklists of medicines may reduce the risk of them ordering a discontinued medicine.

Figure 2: Avery et al. adaptation of Reason's 'swiss cheese' model to illustrate risk in medicines management.⁶³ Reproduced with kind permission.

Deeper integration of the pharmacist into the patient pathway, for example through discussing new medicines with the patient, would act as an earlier system barrier through increasing their understanding of and confidence in their medicines. There has been a growing acknowledgement that patients can play a meaningful role in their own safety if sensitively empowered to do so, despite both patient and clinician reservations about patient involvement in patient safety.³⁴ Patient vigilance, for example, can increase HCP compliance with safety measures in clinical settings, such as hand hygiene;⁶⁴ in medicines reconciliation following hospital discharge;⁶⁵ and in identifying problems with

14

medicines in primary care.⁶⁶ Furthermore, Furniss et al. recently explored how patients develop resilience strategies, such as developing cues to take

medicines, such as alarms, to reduce the risk of unintentional non-adherence.⁶⁷ The Swedish Lund Integrated Medicines Management Model for care transfers is a team-based approach that included clinical pharmacists performing

medicines reconciliation and review functions to reduce medicines reconciliation errors and readmissions to hospital due to medicines errors.⁶⁸ Rather than being a universal medicines management model, it is an intervention to improve the medicines management of elderly people in hospital. It ends at discharge with medicines reconciliation and a discharge medicines report. The report, which details medicines changes and organises the medicines list by time of day, was found to reduce medication errors after discharge and the need for medical care caused by medication errors.^69,70

Stowasser et al. mapped a universal medicines management pathway that is both independent of the care setting and the type of medicine.⁷¹ The patient is involved at the different, largely interdependent stages, as shown in Figure 3 The patient (‘consumer’) is described as the focus of the pathway and interacts with its many stages. It is supported by three background processes: medicines procurement, reporting and quality and safety audit to monitor safety, and communication, which they describe as a vital process to keep patients informed about their treatment and to ensure information between healthcare providers is transferred accurately. The model is comprehensive yet, despite its central positioning of the patient, its focus falls on professional processes rather than on the patients themselves and as such it does not specify the patient-centred care now recommended.⁷²

For example, keeping patients informed about their treatment falls short of current recommendations to give patients the opportunity to make informed decisions about their care. It also fails to communicate the range of

professionals who are involved in the different stages and the multi-professional nature of many of the stages, for example in monitoring medicines, which may be done by doctors, pharmacists, nurses or a combination of all three. In Figure 4 I have developed Stowasser’s model, drawing on current patient-centred approaches that take into account the patient’s own preferences.⁷²

15

Figure 3: Medicines management model from Stowasser et al. ⁷¹ CONSUMER

• Medicines procurement

• Reporting and audit

• Communication

16

Figure 4: A patient-focussed adaptation of Stowasser et al.’s 2004 medicines management model.