Pharmacists have historically provided monitored dosage systems (MDS) like dossette boxes to patients in need, who would have initially been identified because of noncompliance with prescribed medication regimes for varying causes.
When it comes to MDS, pharmacists have historically worked with a lack of guidance or standards, in isolation, and often with no help from superiors or head office.
Often this isolation was as a result of no engagement or funding from the NHS, as there was no recognition of the need or value of MDS as intervention in the ‘care’ of the patient.
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With time and proactive work pharmacists, the value of dossette boxes, blister packs and MDS gained popularity as they proved their value in medication compliance, and helped different carer groups provide timely managed care to patients in different care settings.
Despite this progress, there was still never any guidance surrounding MDS, and pharmacists were - and are - doing things however they decide, unchecked and unmonitored, except by their own initiatives.
Still, offering MDS is a valuable service, and has proved its value in helping prescribed medication compliance in needy patients, especially those affected by mental health issues of varying causes and degrees. Patients suffering from limited dexterity of fingers and hands were also helped.
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With regards to this case, the coroner’s comments, and subsequent declarations of the various authorities (CPE, GPHC, NPA and others), my observations are as below:
There is no formal arrangement in the NHS of funding or requirements of pharmacies to supply MDS or guidance (unless local health authority has commissioned the service).
Where a local HA has commissioned the service there is no prescriptive guidance in the format of delivery of service.
Any medication related incident has numerous contributing factors, and I feel it is simplistic to highlight similar looking MDS packs as a cause leading to the outcomes.
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There is absolutely no evidence to show that different looking, or different coloured packs, would have altered outcomes in this case.
A patient’s mindsets, mental makeup, confusion, medical conditions and similar looking meds within the MDS packs are all factors which contribute to medication errors.
These factors also affect normal full capacity patients who are often confused by LASA (look alike sound alike) meds which are also often a source of dispensing errors.
Often manufacturers are irresponsible in manufacturing LASA meds despite being fully aware of the possibility of errors. No doubt having different looking or different coloured packs for different meds helps, but are not proven to be a standalone solution.
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The coroner observed a small dispensing label with their individual names, but this is the norm, and a reality of the way millions of prescribed medications are labelled every day. And this is unlikely to change unless there is a new failsafe option.
Let us accept that this present situation is far better with computerised labels than having handwritten labels, which was the norm when I first registered as a pharmacist way back in 1981. God knows how many medication errors took place then.
It was sad to notice that the NPA was quick to point out that Lloyds were not NPA members. But I question if the outcome in this case would be different if Lloyds were NPA members?
I recognise the value of the coroners concern, and I accept that having different coloured MDS packs may help confused old patients properly identify packs.
As a direct result of this case, I have updated my SOP to attach different colour-coded sticky labels for patients on MDS in same household, using pink for female, blue for male and red for diabetic.
Subhashchandra Vyas is a community pharmacist of 43 years