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The use of compliance aids/monitored dosage systems by nurses/midwives in health care settings where there is no on-site pharmacist cheap lisinopril 17.5mg with mastercard prehypertension in pregnancy. Health service providers may employ an external pharmacy to dispense many medications to patients/service-users in pre-packaged compliance aids/monitored dosage systems ready for administration by the nurse/midwife to the patient/service- user cheap lisinopril 17.5mg online blood pressure medication depression. Supporting Guidance • Caution should be exercised and the professional judgment of the nurse/midwife must remain the guiding factor when these systems are utilised • Nurses and midwives should have appropriate in-service education regarding these systems generic 17.5 mg lisinopril with mastercard blood pressure up pulse down. The nurse/midwife employing such an aid in the practice of medication management is accountable for her/his actions. She/he should be competent in undertaking this activity • The use of compliance aids is not supported in acute care settings, areas where the range and type of medications is extensive or changes frequently (e. References and resources should be readily accessible for the nurse/midwife to confirm prescribed medication in the compliance aid with identifiable drug information, e. These practices should be supported by locally devised medication protocols where appropriate. The nurse/midwife should monitor the patient/service-user, document the nursing/midwifery action and communicate her/his actions with other members of the health care team, consistent with the health service provider’s policies and the patient’s/service-user’s overall plan of care. The drugs are categorised into five schedules with different controls applicable to each category. The nurse/midwife manager (or acting manager) in charge of a ward, theatre or department may be supplied with a controlled drug, solely for the purpose of administration to patients/service-users in that ward, theatre, or department, on foot of a requisition issued by her/him in accordance with the directions of a medical practitioner. Supplies of controlled drugs for patients/service-users in private hospitals and private nursing homes should be obtained by way of a medical prescription as if the patients/service-users were in their own homes. Private hospital and private nursing home patients/service-users are considered to be in the same position as a patient/service-user in her/his own home. Private hospitals and private nursing homes may hold licenses under the Misuse of Drugs Acts, 1977 and 1984. These licenses legally permit the supply, distribution and control of scheduled controlled drugs for private hospitals and private nursing homes similar to the arrangements in use in institutions as detailed above. It is recommended that local health service providers should consider including requirements expected for the checking, preparation, administration or destruction of these drugs when establishing medication management policies. They should also consider whether these activities are to be witnessed and by whom (i. The nurse/midwife manager or her/his nurse/midwife designee should keep the keys of the controlled drugs storage on their person. In the community, individually prescribed medicinal products, including controlled scheduled drugs, are the property and responsibility of the individual patient/service-user. Unused or expired controlled drugs should be returned for destruction to the pharmacy from which they were dispensed. Standard There are specific requirements for this possession: • A written order is signed by the midwife and countersigned by a medical practitioner or registered nurse prescriber practising in her/his area The medication order must state: • The name and address of the midwife • The quantity to be supplied • The purpose for which it is required. A record must be kept in a book by the midwife of any supply of pethidine that she/he obtained and administered. The record must include: • The name and address of the person from whom the drug was obtained • The amount obtained • The form in which it was obtained. This book should be kept for a period of two years from the date on which the last entry was made. They should be stored in the appropriate environment as indicated on the label or packaging of the medicinal product or as advised by the pharmacist. Medicinal products should be stored separately from antiseptics, disinfectants and other cleaning products. Mobile trolleys and emergency boxes storing medicinal products should be locked and secure when not in use. Policies and procedures should be in place for: • Ordering medicinal products from the pharmacy • Checking delivery and inventory of medicinal products to the ward/unit and maintaining records • The immediate reporting and investigation of discrepancies in medicinal products’ stocks • The storage of medicinal products for self-administration by patients/service-users. Medication errors are defined as preventable events that may cause or lead to inappropriate medication use or patient/service-user harm while the medication is in the control of the health care professional or patient/service-user. These events may be associated with professional practice, health care products, procedures and systems. They include prescribing, order communication, product labelling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use (National Coordinating Council for Medication Error Reporting and Prevention, 1998). For the purposes of this document, the activity of supply is included in this definition. Additionally a "near miss" event or situation may also happen with medications, where the error does not reach the patient/service-user and no injury results (e. If a medication error has been identified, medical and nursing interventions should be implemented immediately to limit potential adverse effects/reactions. Supporting Guidance Health service provider management, and organisations outside of the traditional health care settings where nursing/midwifery care is provided, should support an open culture (non-punitive approach) for error and near miss reporting, while undertaking a comprehensive assessment of the circumstances of the error and, where appropriate, institute action plans to prevent/eradicate the contributing factors to the medication error. The prevention, detection and reduction of medication errors and near misses should occur in collaboration amongst the health care team, as errors may reflect a problem with the system and may involve other professions and departments. Continuous quality improvement programmes for monitoring medication errors and near misses should be in place within risk management systems of the organisation. Fostering cultures of safety and continuing professional development in medication management for nurses and midwives are important in preventing and addressing the causes of medication errors. The prescriber has the professional responsibility for the use of such medications. Standard A nurse or midwife who administers the unauthorised medication or administers a licensed medication for "off label use" should be aware of the indications for the medication’s intended use in providing care to the patient/service-user. Supporting Guidance This medication management decision should be justified by evidence-based practice. It is advised that the nurse/midwife refers to the medical practitioner who has prescribed the medication if there are questions regarding the indications for its use for the patient/service-user. Additional information and support may also be available by contacting the pharmacist. The medication management policies of health service providers should address the topic of unauthorised/unlicensed medication use, including "off label" use. If a health service provider does not have such a policy in effect, it is recommended that one be considered. The input of the pharmacy department, drugs and therapeutic committee (if established), nursing and medical management and risk management is critical in the multidisciplinary effort to develop and implement safe practices involving these medications. Consequently, if a nurse or midwife decides that a change in the form of the drug is necessary for its safe administration, she/he should consult with the medical practitioner and pharmacist to discuss alternative preparations or forms of administration for the patient/service-user. Development of a policy to support the practice of crushing oral medications, inclusive of guidelines and decision-making rationale for individual events, should also be considered. Considerations for safe practice for crushing include preparing a list of medications which should not be crushed or chewed that is placed in a readily accessible location (e. This list should be updated regularly by the pharmacist and whenever a new product which requires specific instructions becomes available. Continuous quality improvement processes should review whether such practices are effective. Occupational health and safety issues regarding the handling, administration and disposal of waste of certain altered dose medications (e.
Examples of this are Spain and Italy purchase 17.5mg lisinopril fast delivery heart attack mp3, where the regions have high autonomy in outlining clinical guidelines and organization regional/hospital formularies discount generic lisinopril uk arrhythmia icd 9 2013. As a result buy lisinopril pills in toronto blood pressure study, regional formularies dictate treatment which could vary access significantly within a country. Final Report Page 37 Access to medicines for multiple sclerosis February 2014 Charles River Associates 3. All markets provide access to all interferons and Glatiramer acetate (with the exception of Austria which doesn’t provide access to Extavia). Final Report Page 38 Access to medicines for multiple sclerosis February 2014 Charles River Associates 86 reasons. Final Report Page 39 Access to medicines for multiple sclerosis February 2014 Charles River Associates who have failed to respond to a full and adequate course (normally at least one year of treatment) of beta-interferon,94 (patient group 1), as well as patients with rapidly evolving severe relapsing remitting multiple sclerosis95 (patient group 2). A “non-responder” could also be defined as a patient with an unchanged or increased relapse rate or ongoing severe relapses, as compared to the previous year. However, this is not the case in all countries, for example, Italy and the Czech Republic have imposed restrictions on patient group 1. We determined the time of availability as the point when significant uptake began (the month at which unit sales as a percentage of the latest month, increased over the previous month by several percent). We would expect that countries with higher income pay higher prices, but access could depend on the affordability of medicines (and associated medical costs). These were in some cases publically available prices published on the local authorities’ webpages (e. If the ex-factory price was not available, but the pharmacy or public price was, we used an estimated price based on average industry margins (e. As with any analysis of prices, this is based on list prices and does not include confidential rebates and discounts. Novartis revised its analyses for a subgroup of the licensed population, so Fingolimod is now recommended for this subgroup, i. We created an index using the level of prices and expenditure in Germany as the base. Following Kobelt we determined the price index using the weighted average price for each drug for each country and divided this by Germany’s price. Another way to examine this is to create an ‘affordability index’ as created by Kobelt. This is calculated by combining the relative price of medicines paid by each country with the total level of healthcare expenditures into one index. A higher index means that it is more difficult for the country to afford innovative medicines. The affordability index has exhibited a decrease in all Eastern European countries as well as in some Northern European countries (Finland and Denmark) meaning that treatment has become more affordable in these countries. This is most likely due to increases in uptake of new innovative medicines used as second line treatment as shown in section 2. These patient registries have helped to collect secondary data related to patients with a specific conditions and play an important role in improving the management of care, as well facilitating post marketing surveillance. Table 11 provides an overview of existing national registries that have been developed in Europe. Final Report Page 47 Access to medicines for multiple sclerosis February 2014 Charles River Associates 3. However, within Western Europe, differences in access are explained by restrictive reimbursement decisions as well as by a clear lack of neurologists in some countries. There are also still some important variations in the product entry/uptake with some countries exhibiting a significant delay. They provide a key tool in managing diseases and have become useful for studying disease characteristics in large populations and monitoring the long-term outcome of disease- modifying therapies. This helps provide information on the provision of treatments, services and supplies within a given area. Final Report Page 48 Access to medicines for multiple sclerosis February 2014 Charles River Associates 4. As shown in the figure below, there is often even more variation within regions of the same country. Even if we consider a country such as Sweden, where access is transparent and has been tracked over time, significant variation continues to persist (see Figure 16). Over the last decade, the Swedish healthcare system successfully reversed this treatment trend such that 60. However, there is still a wide range in terms of treatment rate within Sweden (see Figure 16). The McDonald criterion has provided a uniform approach but has not been universally accepted. It is argued that given there are European guidance for standard treatments and therapies - such as the European Code of Good Practice – these need to be more consistently applied. Final Report Page 51 Access to medicines for multiple sclerosis February 2014 Charles River Associates treatment should be initiated, as consensus is reached so that they are communicated to all audiences. This includes the implementation of guidelines relating to care and treatment, measure the improvements that have taken place, and reveal shortages and/or misalignment in health care services. See, for example, “When to Initiate Disease-Modifying Drugs for Relapsing RemittingMultiple Sclerosis in Adults? Optimising the assessment and approval process It is important to recognise that across Europe healthcare budgets are under unprecedented pressure but when new treatments are launched on the market, the administrative process for assessing the medicines should be as efficient as possible. In some countries, there is clearly a process for systematically allowing for these. In other systems, some effort has been made to allow the societal perspective to be taken into account in some way but this appears to have considerably less impact on decision-making than evidence on health benefits and costs to the healthcare system. For treatments where quality of life is a significant factor, long-term benefits are difficult to measure, but the impact on extended families and carers is significant, and the ability of the patient to work is highly likely to be affected. Mechanisms such as managed entry schemes and coverage with evidence development may be appropriate for particular products to ensure that patient access occurs on a timely basis. Improving affordability and removing administrative barriers As we have set out in the previous chapter there is a relationship between access and affordability. Some policies prevent prices from reflecting the level of income of each market, such as inappropriate international price benchmarking where high income countries adjust their prices towards those in low income countries. These practices as well as the promotion of 107 Ibid 108 Most people are diagnosed between the ages of 20 and 40, and for half of them unemployment follows, on average three years after. In Romania, urgent cases are fast tracked, which raises the question of how a case should be prioritized, i. D18046-00 Final Report Page 54 Access to medicines for multiple sclerosis February 2014 Charles River Associates price benchmarking, where high income countries adjust their prices towards those in low income countries.
Where existing storage volumes of 15% hypochlorite are greater than 28 days buy lisinopril on line heart attack trey songz, consideration should be given to lowering the concentration of product delivered to 10% or lower in order to extend the product shelf life order 17.5 mg lisinopril free shipping blood pressure medication when pregnant, reduce the rate of degradation and the consequent formation of chlorates purchase 17.5mg lisinopril with amex blood pressure 5 year old boy. Dosage rates must be adjusted by operator in accordance with an operating procedure to compensate for progressive loss in chlorine content due to the storage age of chemical. Hypochlorite storage and dosing installations The design of storage installations should pay particular attention to spill containment including containment for 110% contents of the largest tank, no uncontrolled floor drains, an overflow from chemical storage tanks that discharges to the containment area and separate containment areas for incompatible chemicals should be provided. Where fiberglass is used for reinforcement in tank walls, the fibres must be protected from the sodium hypochlorite with a sufficient depth of coating. Vent(s) from bulk tanks should be sized at 100-150% of fill pipe diameter to prevent excess pressures or vacuum during filling and should be terminated at a suitable external location, remote from air intakes, doors, windows, and parked vehicles, in a downward aspect with a fine corrosion resistant mesh to prevent contamination. Fill points should be located directly over containment area and provision should be also made for a ball shut off valve to prevent backflow of chemical when hose is disconnected, and to guard against any unauthorized filling without the presence of appropriate site personnel. A liquid sensor that activates audible and visual alarms, at a high level set point, should be provided on bulk storage tanks. The alarms must be mounted at locations that will alert both the treatment system operator and tank truck delivery driver to prevent overfilling of bulk tank(s). Emergency overflows from tanks should discharge to the containment area at a level of typically 300mm from floor level. To cater for accidental splashes of hypochlorite chemicals on the skin or in the eyes, emergency eye washes and showers should be provided between the location of the hazard and the nearest means of egress. These drench showers and eyewashes should be located throughout the facility following on-site risk assessment of accidental exposure. Flush eyes and skin for at least 15 minutes and seek medical treatment after exposures. Where drums are used, provisions should be made for disposing of drums in accordance with a site- specific procedure which will prohibit rinsing out of drums, prevent their exposed to internal contamination and minimize personal and environmental exposure to chemicals. As with all hazardous chemicals, feed lines should be ideally routed overground along cable trays through readily accessible floor ducting. Underground buried ducting should be avoided unless secondary contained within a sealed sleeve. Feed lines should be color-coded yellow, labelled with chemical name, and show arrows to indicate direction of flow. Control of gasfication Operators should be aware, when taking delivery of Sodium Hypochlorite that the solution is active particularly at higher concentration and will release a large proportion of gas in solution and during subsequent degradation during subsequent storage. The release of gas from the solution temporarily affects the dosing system by creating a gas lock in the dosing system resulting in a loss of prime and a lower applied chlorine dose for that period. After receiving a delivery of sodium hypochlorite, it should be allowed to stand for a few hours or over night, before utilizing the chemical to liberate much of the gas contained within the liquid. The concentration of bulk sodium hypochlorite deliveries should be monitored relative to specification particularly following a new delivery but also on an ongoing basis, as the stocks of hypochlorite ages, so that chlorine dosing can be adjusted accordingly. The most common dosing systems use diaphragm metering pumps with a pulsation damper, a pressure relief valve, a calibration cylinder and a loading valve. Some dosing pump suppliers offer auto-degas valves systems as part the dosing system design. Gas is typically removed from the suction line through a vent valve and directed back to the storage tank with a small amount of liquid. Bulk hypochlorite dosing systems should be installed with a flooded suction to aid in the prevention of gasification. Pump suction lines should be always below the minimum tank liquid level and be installed downwards from the tank to the pump. Delivery lines should slope upward from the metering pump without loops or pipe configurations which will trap sodium hypochlorite between two closed valves and be fitted with anti-siphon valves. Relative to commercial sodium hypochlorite (5-15%) it is less hazardous and also a more stable chemical compound. Most proprietary systems also possess automatic safeguards which shut down the system if a fault is detected. Consequently a parallel room ventilation system will assure the hydrogen gas is quickly dispersed. As hydrogen will rise to the ceiling, the room ventilation system should be designed to provide for exhaust air to exit near the ceiling. The vent should exceed the size of the tank’s largest inlet or outlet nozzle by two inches. The vents should have a vinyl insect screen attached to the end to keep debris or insects out of the tank. Every atmospheric pressure rated tank must be protected at all times by properly sized vent pipes in order to prevent build-up of pressure or vacuum conditions. Operators should never remove an access hatch or work on the storage tank until the requirements of a site specific operating procedure has been complied with. Calcium Hypochlorite Calcium hypochlorite is another chlorinating chemical used infrequently in an Irish context. It is used primarily in smaller water supply disinfection applications and in swimming pools. It is a white, dry solid containing approximately 65% chlorine, and is commercially available in granular and tablet form. Calcium hypochlorite is particularly reactive in the solid form with associated fire or explosive hazard if handled improperly. All forms of calcium hypochlorite should be properly stored in accordance with manufacturer’s instructions in a cool, dark, dry place in closed corrosion resistant containers. Calcium hypochlorite should be stored away from heat and organic materials that can be readily oxidized. Improperly stored calcium hypochlorite has caused spontaneous combustion fires in the past Granular calcium hypochlorite, if stored out of closed containers can lose about 18% of its initial available chlorine in 40 days. Consequently stocks should be dated and controlled and used in rotation so as to minimise deterioration in storage. Solutions should be prepared on a batch basis for use following mixing and special provision for the separation of diluted calcium hypochlorite from inert materials as follows: from granular product, by the provision of a separate mixing tank upstream of the dosing tank and mechanically mixing. Following proper mixing the inert insoluble material is allowed to settle prior to decantation of the dissolved liquid only to the dosing tank. Hygiene and good housekeeping at treatment/disinfection installations Due to the importance of water as a food product, the importance of good hygiene practices by operators and the elimination of the potential public health hazard posed by uncontrolled ingress by 176 Environmental Protection Agency Water Treatment Manual: Disinfection Appendix 2. Where appropriate, this training should include the actions required if one of these personnel has an illness (for example gastroenteritis or Hepatitis A) that could pose a risk of contamination of the drinking water supply or spread of the illness to other personnel. Hygienic practices are particularly important for multifunctional personnel who may work on both water supply and sewage. This scheme consists of completing a health questionnaire, receiving comprehensive water hygiene training and successfully passing a multi- choice test paper. All buildings and storage areas shall be kept and maintained in a clean and sanitary condition. No rubbish or other waste shall be permitted to accumulate or to remain in any area which may afford food, refuge or a breeding place for rodents. All equipment, drums and other material stored placed on pallets elevated above the ground or floor, with a clear clean space beneath.