NPSA Patient Safety Alert - Safer Lithium Therapy Action Plan
This patient safety alert, issued in December 2009, identifies 5 key areas to improve the safety of lithium therapy. The majority of
patients, whilst having lithium initiated by prescribers within the mental health trust, are prescribed lithium on an ongoing basis in
primary care so this action plan also considers joint working with other NHS organisations in Cambridgeshire and Peterborough.
NPSA Actions
Patients prescribed
lithium are monitored in
accordance with NICE
guidance
Local Actions
Update the Trust lithium
monitoring guidelines to
include reference to NICE
guidance
recommendations and
take to Cambridgeshire
Joint Prescribing Group
for approval and
dissemination to primary
care organisations.
Include the requirements
for Lithium prescribing,
monitoring and
dispensing in the Trust
Mandatory Training for
Prescribing and
Medicines Management.
CPFT NPSA Lithium Patient Safety Alert Action Plan
Author Clare Mundell Version 1 March 2010
Progress
CM
By whom
By when
May 2010
CM
April 2010
Completed
1
There are reliable
systems to ensure that
blood test results are
communicated between
laboratories and
prescribers
At the start of lithium
therapy and throughout
their treatment patients
receive appropriate
Reaudit Lithium
prescribing and
monitoring as part of the
POMH reaudit
programme and
subsequently to evaluate
local action specifically for
this alert.
SC/Clinical Audit
April – July
Department/Junior 2010
Doctors
Establish current situation
with regards to
accessibility of blood test
results within CPFT
Pharmacy Team
March –
April 2010
Speak to PH, Head of
Informatics about how to
ensure electronic access
to blood results for CPFT
prescribers and
pharmacists.
CM
April 2010
Implement electronic
access for blood test
results or if not possible
alternative solution.
??
October
2010
CM/SC/RS/CH
June 2010
Obtain NPSA booklets
and distribute to all
current patients.
CPFT NPSA Lithium Patient Safety Alert Action Plan
Author Clare Mundell Version 1 March 2010
Jan – Mar
2011
Jan 2010 – Meeting with
RS, CH and LO to
propose method of
dissemination in
2
ongoing verbal and
written information and a
record book to track
lithium blood levels and
relevant clinical tests
Peterborough (detailed in
NHS Peterborough
Action Plan.)
Need to speak to DM/VS
to establish process for
Cambridgeshire if
possible.
CM
March 2010 – 400
booklets delivered
Communicate details of
the alert to all CPFT
doctors and teams
including availability of
booklets, the need to
ensure that all patients
are given the opportunity
to have one and our
responsibilities in
completing certain
sections.
Included a letter sent to
all doctors from the
Medicines Management
Committee 11/03/10
CM
March 2010
Email sent to all team
managers for
dissemination to teams
11/03/10
CM
March 2010
Include in CPFT Team
Brief and Medicines
Management Extranet
page
CM
April 2010
Pharmacy staff to start
distributing booklets to
new and existing
SC/SW/BG
March 2010
CPFT NPSA Lithium Patient Safety Alert Action Plan
Author Clare Mundell Version 1 March 2010
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inpatients
Prescribers and
pharmacists check that
blood tests are monitored
regularly and that it is
safe to issue a repeat
prescription and/or
dispense the prescribed
lithium
Systems are in place to
identify and deal with
medicines that may
interact with lithium
therapy
Include these
expectations in the Trust
Lithium Guidelines
CM
May 2010
Review pharmacy
dispensing SOPs and
update them to include
appropriate checks of
lithium blood levels and
clinical tests and what to
do if the tests have not
been undertaken.
SW/SC/BG (in
conjunction with
acute trusts if
necessary)
May 2010
Include the need for
prescribers and
pharmacists to check the
current status of lithium
blood tests when
prescribing or dispensing
lithium in the revised
lithium guidelines.
CM
May 2010
Produce a quick
reference interaction table
for use by all prescribers
and pharmacy staff – as
an addendum to the Trust
lithium guidelines and to
share with other
SC/LO
May 2010
CPFT NPSA Lithium Patient Safety Alert Action Plan
Author Clare Mundell Version 1 March 2010
4
organisations
Send the CPFT action
Plan emailed to RS, LO,
CM
March 2010
plan to other NHS
AD, VS, DM, CH, CMc,
Organisations in
SCo, NB, LB – 10/03/10
Cambridgeshire and
Peterborough for
information and
comments.
CM – Clare Mundell, Chief Pharmacist, CPFT
POMH – Prescribing Observatory for Mental Health. CPFT took part in the initial POMH national audit that informed the production
of the NPSA alert.
SC – Pharmacist Team Manager, Peterborough, CPFT
SW – Pharmacist Team Manager, Cambridge, CPFT
BG – Specialist Pharmacy Technician, Hinchingbrooke
LO – Lucy Oakley, Pharmacist, PCS
AD – Ann Darvill, Pharmacist, CCS
VS – Val Shaw, Pharmacist, NHS Cambridgeshire
DM – Debbie Morrison, Pharmacist, NHS Cambridgeshire
RS – Pharmacist, NHS Peterborough
CH – Claire Hart, Pharmacy Technician, NHS Peterborough
CMc – Claire McIntyre, Pharmacist, Peterborough and Stamford Hospitals
SCo – Stephen Cook, Pharmacist, Hinchingbrooke
NB – Narinder Bhalla, Pharmacist, Addenbrookes
LB – Liz Bligh, Pharmacist, Papworth
CPFT NPSA Lithium Patient Safety Alert Action Plan
Author Clare Mundell Version 1 March 2010
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