Safe use of medicines in mental health: a whole-system approach

Anna Bischler
Hello, I’m Anna Bischler, Associate Director for Medication Safety at SPS, that’s Specialist Pharmacy Service. So today I’m joined by Vanessa Earnshaw, a Senior Medication Safety Pharmacist with me in the team in SPS. And we want to spend some time exploring why a focus on specialist mental health medicines and the safe use of physical health medicines in patients with mental health conditions is so important. So we will plan to share some details of a programme of work that our medication safety team in SPS are doing, where we’re focusing on this topic and showcasing good practice or showcasing actions that we can take as healthcare professionals to make the use of medicines safer. This focus that we’re talking about forms part of our ongoing Medicines Safety Across the Systems [MSATS] programme. So Vanessa, hello. Can you start us by sharing why this focus within medication safety work is so important.

Vanessa Earnshaw
Absolutely, thanks, Anna. So we know that people with mental health conditions often receive care from multiple organisations throughout their journey, and we wanted to really understand where medication safety risks occur, what the challenges staff are facing and where improvements can be made. We also know that people living with severe mental illness experience significant health inequalities. They’re more likely to have long term physical health conditions such as diabetes, heart disease and sadly experience poorer health outcomes. For me, medication safety is a key part of tackling these health inequalities. Delays in accessing medicines, gaps in monitoring poor communication between services, and challenges managing both mental and physical health medicines can all affect patient outcomes. And that’s why understanding and addressing these risks is really so important.

Anna Bischler
Absolutely. Thanks, Vanessa, for sharing that insight and addressing inequalities is, is just such a priority within our medication safety work. Now, Vanessa, at the start of this programme of work, we knew that we needed to understand what medication safety challenges our healthcare professionals, healthcare professionals out there are experiencing across the system. So to get that level of understanding, I know, Vanessa, you undertook an engagement exercise. Can you tell us a little bit more about why we did that and what we learnt from it?

Vanessa Earnshaw
Yeah. So the engagement exercise, it’s given us really valuable insight from colleagues working across different sectors and highlighted some common themes across the system. So we had over 197 healthcare professionals engage with the survey, and 94% of those said they experienced medicine safety challenges. We had responses from a variety of different healthcare professionals. So pharmacists, pharmacy technicians, nurses, doctors and allied healthcare professionals. Perhaps the most striking finding was that medication safety challenges are experienced across all healthcare settings. The safety challenges are not isolated to any particular care setting, and the challenges occur across the whole system, so primary care, mental health services, acute hospitals, community settings and care homes.

Anna Bischler
Oh that’s fantastic. So it sounds as though you had quite a positive and large response, but also from, from quite a range of care settings. Did you find, were there any particular points in the patient journey where the risks seemed the greatest?

Vanessa Earnshaw
Yeah, one of the strongest themes, which is probably not surprising to the listeners, but was, it’s around transitions of care. Whenever patients move between services, organisations or care settings, the risk of that medication related problem increases. So information doesn’t even, doesn’t always transfer smoothly, responsibilities become unclear, and patients can find themselves navigating those complex systems. And interestingly, admissions to and discharges from acute hospitals that came out in the survey as one of the highest medication safety challenges across the care journey.

Anna Bischler
Interesting. Yeah, yeah, no. We know communication and transfer of information often comes up as a medication safety challenge when we look at other therapeutic groups of drugs or specific patient groups. Was that reflected in your feedback for medications for mental health conditions?

Vanessa Earnshaw
Yeah, very much so. So many respondents highlighted difficulties accessing accurate and timely information, challenges obtaining medication histories, monitoring results, discharge information. When information isn’t readily available, it’s obviously harder to make those safe clinical decisions and ensure that continuity of care. And I guess in practice, it can mean a clinician doesn’t always have access to the recent blood test results, isn’t aware of a medication change that’s been made elsewhere, or can’t easily confirm what medicines a patient is actually taking. So every individual issue on its own may seem small, but together they create that system wide risk for patients.

Anna Bischler
Really challenges, challenging, isn’t it? Were there any particular medicines that respondents highlighted as presenting safety challenges?

Vanessa Earnshaw
Yeah. So several medicine groups feature prominently in the engagement exercise, particularly clozapine, lithium, long acting injectable antipsychotics (often referred to as depot injections). So yeah, quite a few.

Anna Bischler
Yeah. Okay, well, let’s start with the clozapine then. What challenges specifically were identified with that medicine?

Vanessa Earnshaw
Yeah. So clozapine that generated significant medicine safety challenges across the system. So respondents highlighted concerns around treatment interruptions, accessing blood monitoring information, the communication between acute hospitals, mental health services and primary care. There were some examples where healthcare professionals outside of mental health settings were less familiar with clozapine specific requirements, including what actions to take following missed doses or treatment breaks, how to manage clozapine induced constipation and gastrointestinal hypomotility, which is a side effect that potentially causes death if it’s not recognised or actively treated. So that really reinforced the need for education, clear pathways and access to that specialist advice across the system.

Anna Bischler
Again, that is something that we, we hear quite a lot with other medications as well when you’ve got specialist medicines being used by generalists and kind of patients interfacing with, with the generalists in other care settings. So let’s move on. Lithium, what about lithium?

Vanessa Earnshaw
Yeah. So lithium. Colleagues highlighted challenges around blood monitoring, test results, making sure monitoring information follows the patient across the services. And we also heard concerns about communication when patients are admitted or discharged from hospital, where access to those up to date lithium dosage information and monitoring results are really critical for those safe decision making.

Anna Bischler
Yeah. So coming back with this, this communication theme again, isn’t it?

Vanessa Earnshaw
Yeah, definitely.

Anna Bischler
So what about long acting injectable antipsychotics? They also came through quite strongly in the survey findings.

Vanessa Earnshaw
Yeah they did. So common themes included communication of administration dates, clarity around responsibility for the administration, ensuring accurate records were available when patients move between the services. Respondents describe challenges around delayed, missed, omitted or even duplicate doses, as well as errors due to risk of look alike, sound alike medicines.

Anna Bischler
Yeah. So there we have omitted and delayed medicines, we’ve got risks of ‘LASA’, so the look alike sound alike.

Vanessa Earnshaw
Yeah.

Anna Bischler
So, again, these are all very different medicines, but the challenges are incredibly similar to, to, to all medicines really aren’t they?

Vanessa Earnshaw
Yeah. That’s it. So while each medicine has its own clinical considerations, the underlying safety issues were surprisingly consistent. So communication, transfer of care, monitoring, access to information and that clarity of responsibility. It suggests that many of the risks are system issues rather than medicine specific.

Anna Bischler
Yeah but were there any challenges, though, that were limited to medicines used specifically for mental health conditions?

Vanessa Earnshaw
Well, respondents also highlighted significant challenges not just to mental health medicines, but to the physical health medicines as well.

Anna Bischler
Okay. Can you give us some examples of that?

Vanessa Earnshaw
So insulin was one of the medicines frequently mentioned. So colleagues described concerns around diabetes management in mental health settings, so in that specialist setting of mental health. If there was a change in the clinical condition, the communication between services and access to the specialist advice when needed. So they did share challenges relating to a range of physical health medicines, so anticoagulants, cardiovascular medicines, Parkinson’s disease medicines, and uncertainty around who is responsible for reviewing and managing these medicines when patients move between services or they’re receiving treatment predominantly focussed on their mental health needs who’s looking after those physical health medicines?

Anna Bischler
Yes. So I guess what you’re saying is, so what the survey’s highlighting is that when we’re looking at the safe use of these, these medicines and looking at the safe use of medicines within this population, we’re looking beyond medicines for the mental health conditions.

Vanessa Earnshaw
That’s exactly it. So medication for people with mental health conditions isn’t just about mental health medicines. Patients often have like long term physical health conditions. And safe care requires us to think about both the mental and the physical health medicines together and ensure they’re managed holistically throughout their patient journey. So I guess patients, they don’t separate out their mental and physical health so as healthcare systems, we shouldn’t either.

Anna Bischler
Yeah, absolutely. It’s something that, that’s kind of a key message for us all to think about really, isn’t it? I guess that also kind of leads us nicely onto another challenge that we know, which is about shared care, where with this responsibility for healthcare professionals about who’s looking after the patient. Did that come up at all?

Vanessa Earnshaw
It did. That was again, another recurring theme. So respondents describe situations where responsibility for prescribing, monitoring and reviewing medicines wasn’t always clear, and sometimes services assumed another organisation was managing that particular aspect of care. So the reality is that patients need that seamless care regardless of organisational boundaries. I guess the medication safety it doesn’t sit with a single organisation, it relies on that effective collaboration between mental health services, primary care, acute trusts, community providers and also includes community pharmacy. So everyone really has a role to play in this.

Anna Bischler
Thanks, Vanessa. Can you just talk us a little bit, I’m sure there probably were some challenges around staff knowledge and confidence were there?

Vanessa Earnshaw
Yeah, there were. So some medicines used in mental health can be unfamiliar to clinicians who don’t encounter them regularly. So access to that specialist advice, education, resources are really, really important for that safe decision making at that time when, you know, you’re looking after that patient.

Anna Bischler
Absolutely. And I guess that’s particularly relevant when staff are working across different care sectors.

Vanessa Earnshaw
Absolutely. So as healthcare becomes more integrated, it’s important that all professionals feel confident in recognising risks, knowing when to kind of ask for advice and seek that specialist advice and understand those risks as well.

Anna Bischler
Just thinking, lastly, something that always comes up is digital systems. So while supporting us with safety we know that there’s sometimes challenges with using digital systems safely. Did you hear anything back related to that in this cohort of patients?

Vanessa Earnshaw
Yeah. So that did come through. So colleagues described challenges with fragmented systems and limited interoperability. So often the information exists, but it isn’t always accessible to the people who need them at the right time. So improving how that information is shared across organisations could significantly support safer care. So I definitely think digital solutions have a role to play in improving medicine safety.

Anna Bischler
Thanks, Vanessa. Now listening there to your summary of the engagement exercise, I’m hearing that mental health and physical health are very closely intertwined. Do you just want to touch on that a little bit before we finish up?

Vanessa Earnshaw
Yeah, I completely agree with what you’re saying there, Anna. So medication safety for people with mental health conditions is not solely a mental health issue. Physical health conditions, monitoring requirements and medicines used for those long term conditions all play an important role. And safe medicines use requires us to look at the whole patient and the whole system around them as well.

Anna Bischler
Absolutely. Some real key messages there, Vanessa, thank you so much for, kind of, all that insight that you’ve given us in the last few minutes talking. And I think this really reinforces why this focus on medicines used for specialist mental health conditions and the safe use of physical health conditions in patients with mental health conditions is so important. These challenges are shared across organisations and healthcare sectors. So rather than working in silo, we really need to be working together collaboratively, share good practice and identify practical solutions to common problems. And that’s really, isn’t it, Vanessa, that’s exactly what our SPS medication safety across the system program is, is really all about. So within our team here at SPS, we plan to be delivering some webinars, some web pages, and a dedicated networking forum to really kind of focus in on this topic and address some of those issues. So we hope that everyone listening to this podcast will keep an eye out for, for those coming from SPS and, and looking out for them on the website and in our other forums. So people will feel as though they’ve got the resources, but also feel inspired to take actions to improve medication safety as a whole for these, these patient groups and for specialist mental health medicines. Now, Vanessa, before we sign off do you want to just leave us, is there one message that you’d like listeners to take away from today? What would that be?

Vanessa Earnshaw
Oh, it would be that medication safety for people with mental health conditions, it’s everyone’s business. The challenges we’ve identified, they are complex, but they are also shared. And by working together across those organisational and professional boundaries, we have a real opportunity to improve safety and the outcomes for our patients.

Anna Bischler
Great key message, thanks, Vanessa. And thank you, really everyone who contributed to the engagement exercise as well. So we’re going to be looking forward to sharing some more resources and inspiring stories over the next coming months. Thank you for listening.

Vanessa Earnshaw
Thank you. Thanks for listening, everyone.