September 25 was this year’s World Pharmacists Day with the theme: ‘Safe and effective medicines for all’. The theme aims to promote pharmacists’ crucial role in safeguarding patient safety through improving medicines use and reducing medication errors.
“Pharmacists use their broad knowledge and unique expertise to ensure that people get the best from their medicines. We ensure access to medicines and their appropriate use, improve adherence, coordinate care transitions and so much more. Today, more than ever, pharmacists are charged with the responsibility to ensure that when a patient uses a medicine, it will not cause harm,” says FIP President, Dominique Jordan.
Nigerian pharmacists are better placed to safeguard patient safety through medicines optimisation and patient centred care. I have observed that this service tends to be lacking in our primary and secondary care facilities because there is lack of multidisciplinary team approach in some settings. We need to start having these conversations and changing the status quo. A lot of patients using clinical facilities do not come in contact with a pharmacist. They do not get their medicines reconciled or reviewed, which could result to exposure to adverse drug-drug interactions and lack of concordance.
As long as we still have some clinicians in Nigeria diagnosing, prescribing, dispensing medication and ‘hiding’ the name of the medicine from the patient, duplication of therapy, adverse drug reactions and drug-drug interactions are inevitable. Patients have the right to know the medicines they are taking to help achieve concordance and prevent medication errors and overdose.
Medicines reconciliation is a process whereby patient’s medicines are reconciled as they move between different stages of healthcare, from primary-secondary care interface. Pharmacist-led medication review tends to be more in-depth, capturing all the essence of patient-centred care as it offers more time for the patient to ask medicines-related questions which enhances concordance. Medication reviews are needed to highlight issues of blood monitoring, therapeutic drug monitoring for medicines that require special monitoring like methotrexate, diuretics, digoxin etc.
According to the Royal Pharmaceutical Society, “Medicines optimisation represents that step change. It is a patient-focused approach to getting the best from investment in and use of medicines that requires a holistic approach, an enhanced level of patient-centred professionalism, and partnership between clinical professionals and a patient.”
Evidence has shown that a good number of medicines prescribed end up not being taken due to lack of concordance and compliance. My experience with patient-returned medication has shown that patients who do not understand the rationale for prescribed medication are more likely not to use the medication. Also medication used for preventative measures are at a higher risk of non-compliance as patients do not appreciate the benefits of taking such medication.
The gains of patient centred care cannot be overemphasised. All medical needs have to be tailored to the individual patient.
In some clinical settings, a lot of patients do not know what regular medicines they are taking or the reason why it has been prescribed, their indication or side effects to expect and they have never had their medication reviewed by a pharmacist since their long-term condition was diagnosed. Part of the role of the pharmacist in a clinical setting is to complete medicines reconciliation and medication reviews especially for patients taking regular medication for long-term condition like hypertension, diabetes, arthritis, asthma etc. We need to create the enabling environment for this to be achieved.
For instance, a patient living in Kaduna with a history of hypertension, takes antihypertensive–Calcium channel blocker (CCB)-amlodipine tablets prescribed by his local doctor. The patient travels to Lagos on official assignment and falls ill, gets admitted to a hospital, diagnosed with very high blood pressure (HBP), receives treatment and gets discharged with three other medicines which includes another CCB-Nifedipine, without being asked about his past medication history or told what medicines to stop or continue. The patient continues to take two CCB–Nifedipine and amlodipine at the same time and suffers hypotension (low blood pressure), which makes his condition worse. The patient is re-admitted to hospital in Kaduna, his medication is reviewed by a pharmacist, and he is told to stop Nifedipine and continue taking only Amlodipne.
We need to utilise the expertise of pharmacists in all clinical settings. A medication reconciliation process with a pharmacist during the hospital admission/discharge process in Lagos could have prevented the hypotension resulting from a duplication of therapy.
Evidence has shown that when patients understand the side effects of the medication they take, they are more likely to comply with the dosage regimen. All medical needs have to be tailored to the individual patient, considering their personal circumstance. Pharmacists are better placed to undertake this piece of work.
In the course of completing a medication review with one of my patients, It came to light why patient’s chronic obstructive pulmonary disease (COPD) was not well managed .This patient happened to be visually impaired and was unable to read the small-typed instructions on the dispensing label and so assumed Tiotropium capsules needed to be swallowed whole and not inserted into the inhalation device. After I offered education, guidance and support to this patient, she was able to use her inhaler as intended and her COPD symptoms were well controlled eventually. In this case, a possible COPD exacerbation or even hospital admission/death was prevented.
Medication reviews are needed to highlight issues of blood monitoring, therapeutic drug monitoring for medicines that require special monitoring. Annual blood tests are routinely checked because if dosage regimens are not adjusted or vital blood checks are not made, this may lead to increased harm to the patient or even death.
As we work towards achieving SDG3 and universal health coverage in Nigeria, the following simple steps could help reduce the risk of medication errors and medicines related deaths in Nigeria:
First, we have to develop and implement a nationwide strategy which will bring about the desired change in the healthcare system. Second, we need to optimise integrated healthcare and patient centred care using a multidisciplinary team approach. And, finally, we need to begin to put the patient at the centre of care and utilise the pharmacists expertise and input if we must provide safe and effective medicines for all
Finally, the Ministry of Health needs to develop and enforce policies around medicines reconciliation and reviews, especially for patients with long-term conditions who need regular medication to improve their quality of life. They must ensure that ‘drug experts’ are given the opportunity to bring their expertise to the table. Nigerian clinicians need to work together to ensure adequate measures are put in place and everyone contributes their own quota towards effective healthcare delivery.
Adaku Efuribe, a clinical pharmacist and a UN SDGs advocate, wrote through efuribeadaku@yahoo.co.uk
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