Editor's Note: Dose Administration aids (DAA's)are becoming more prominent as their use becomes more universal- not just in a nursing home or other supervised setting.
Given that Australia's "baby boomers" are progressively moving into a reliance on dugs to treat their chronic illness, DAA's are set to become a way of pharmacy life, as a major tool to assist drug administration and patient monitoring - and keeping patients supported in their homes.
However, they are not without their problems as lead-writer Robert Forsythe points out, because he ends up with the problem in the hospital emergency department.
Klaus Petrulis gives us another view and a footnote to this discussion.
Robert Forsythe begins:
At the hospital where I practice we have been fortunate enough to be able to allocate some pharmacy time to our Emergency department over the last 9 months.
The idea of course is that the pharmacist will be skilled at obtaining accurate medication histories making the role of the medical and nursing staff more effective.
The pharmacist is also able to advise on the correct administration of critical care drugs.
Not surprisingly, some other professionals seem to find it difficult to find and interpret the information in what are often life and death situations.
As someone who has dipped in and out of community pharmacy also I have been most shocked by the way on which community pharmacy practices affect the activities of the emergency department.
We in the pharmacy department are starting to understand concerns that ED staff have had for years.
One of my greatest concerns is around the use of DAA’s.
By definition patients who use DAA’s are often less likely to be able to recall their medication regime.
The patient will present to the department with a DAA and the ED staff will use that information to ascertain the medication regime and as a starting point for therapeutic decisions.
Recently, the software for at least one major DAA option has changed and an increasing number of patients are presenting with packs that are not printed on the foil but instead on a header card.
To make matters worse, there is a perforation along the header card under the printing, which gives patients the impression it is something that they should remove.
This is certainly contrary to pharmacy board advice in Queensland.1
Some sachet systems also present dangers if the patient breaks up the pack - staff will get an incomplete picture.
The contents sticker is removed as soon as the patient starts to use the pack.
Another weakness of DAA systems is that patients frequently do not volunteer information about the other medications they take that are not in the pack.
It would be wonderful if DAA systems could provide a reference to all medications taken.
During ‘office’ hours options available to ED staff include calling the patients pharmacy (although one of our pharmacists was once told to call back after the lunchtime rush - when he had a patient in ED in acute heart failure), or their GP and getting the information from there - or using a combination of the pharmacists tablet recognition abilities and MIMs to determine what is in the pack.
This is a time consuming excercise and is not available outside office hours (very few hospitals are currently fortunate enough to have an extended hours ED pharmacy presence).
The result of course is that doctors can make decisions based on incorrect assumptions, with possibly disastrous consequences.
Please - when you are providing DAA’s ........
* Choose a system where the contents and directions cannot be separated from the pack.
Educate patients not to deface in any way.
* Include information about meds not in the pack if possible.
* Talk to patients about keeping an up to date list with them.
* Make time for hospital pharmacists if they call. The information could be critical.
Ref: 1. Pharmacy Board of Queensland (2004). Dosage adminstration aids. Bulletin 19
We posed a recent DAA problem involving contamination of a blister pack that had been recycled, to Klaus Petrulis of Persocare, our expert in these matters.
Because we had heard some thoughts expressed that blister packs would be unable to be recycled in the near future, and could even receive a total ban if the problem became a continuing one, we wanted an opinion from someone in the industry.
"As far as entertaining the idea of of banning blisterpacks, its not reasonable.
Blisterpacks have been around since 1979 and not only in Australia but in all the western world.
We have all realised its benefits of safety, less errors and compliance.
What alternative is there that can provide a sealed tamper evident calender pack like the blisterpack?
Contamination can be a problem in facilities sharing the hardware and handling problems during packing and medication administration by staff.
Hence we have a policy or protocol in place where gloves must be used and and an asepsis policy to swab equipment regularly before repacking, with Isopropyl alcohol.
This is also the reason we were the first people to introduce our Disposapak for community use as we have found that there was lack of care with community users, especially with our indigenous population's hygeine issues.
The only reason this has become an issue is because a Pharmacist being thrifty to save costs chose to reuse blisters which would cost him in labour costs doing such a thing.This was never allowed for in our guidelines and is very much unproffesional and careless let alone irresponsible.
The vendors can not be made responsible for this Pharmacist's action. Finally I am sure 99% of pharmacists involved with PSA have used or are using this form of DAA.
Also the guidelines have been set for the most practical DAA to be used in the DAA services program as being the blisterpack as approved by planning committees from the Govt. and Pharmacy Guild let alone PSA guidelines.