Lectures

Question 1

When was the Nurses Prescribing Formularly created?

Answer 1

1992

Question 2

What years were pharmacists able to train as supplementary prescribers, and then independent prescribers?

Answer 2

Supplementary –> 2002

Independent –> 2006

Question 3

What are the 3 key principles about supplementary prescribing?

Answer 3

Importance of communication between prescribing partners

The need of access to shared patient records

The patient is involved in all stages of prescribing, regadless of who does it

Question 4

What is the main difference between a supplementary prescriber and an indepedent one?

Answer 4

Supplementary –> Works within a clinical mamagment plan (CMP)

Indepedent –> Operates within their own competence

Question 5

What are the 2 domains of the prescribing competency framework?

Answer 5

The Consultation

Prescribing Governance

Question 6

What’s the difference between criminal and civil law?

Answer 6

Criminal –> Breaking of the law

Civil –> Breach of duty of care to a patient (‘tort’)

Question 7

What’s the difference between Utilitarianism and Deontological thinking?

Answer 7

Utilitarianism –> For the many people, not the few

Deontological –> Shouldn’t cause harm to anyone full stop

Question 8

What are the 2 different types of clincal decision making?

Answer 8

Selective –> Options already exist, and we need to select the best one

Creative –> Need to generate options from gained information

• These decisions can inbolve our own emotions and bias…so can be more risky

Question 9

What is the most common reason for clincal errors?

Answer 9

Errors of reasoning or decision quality

Question 10

What is the Six Stage Approach?

Answer 10

Question 11

What is the difference Analytic and Non-Analytic reasoning?

Answer 11

Analytic –> Gathering and weighing of elicited data against mental rules

• Often linked to the evidence base

Non-Analytic –> Use of past-experiences more (eg, compairing past patients to the current patient)

• Often increase with experience
• Rapid/unconcious analysis

Question 12

What are the possible reasons for not monitoring somebody?

Answer 12

Inconvenience

Cost

Impact of possible fake-positives/negatives

Age (is the renal function of a frail elderly women really important?)

Question 13

What are the benefits and negatives of self-monitoring?

Answer 13

Benefits –> Can be motivational, can prevent the number of clinician visits (eg, home BP monitoring), to adjust therapy (eg, insulin levels)

Negatives –> Can increase patient anxiety (meaning small changes will cause them to run to their GP!)

Question 14

When are ADRs most likely to occur?

Answer 14

As the start of treatment or dose increases

Question 15

What 5 things should we think about when designing a monitoring strategy?

Answer 15

Whether to monitor at all!

Choice of measurment(s)

Choice of a target range

Choice of measurment intervals

Who should do the monitoring

Question 16

Define Leadership

Answer 16

The action of leading a group of people or an organisation, or the ability to do this

Question 17

What are the 5 different types of leadership style?

Answer 17

Autocratic –> Makes decisions with no input from others

Paternalism –> Whilst they consult, ultimatly they make the decision themselves

Consultative –> Good connection between themselves and staff to come to agreements (requires high inter-personal skills)

Democratic –> Listens to others perspectives and uses that information to guide his decision (can take longer)

Laissez-Faire –> Hands-off approach, little contact with anyone and lack of decision making

Question 18

What are the 4 domains of situational leadership?

Answer 18

Different leadership styles are often needed for different people in different situations

Supporting/Delegating –> Develops team-members abilities to work independently

Coaching/Directing –> Focused on getting the job done

Question 19

What is the Healthcare Leadership Model?

Answer 19

Question 20

Define Frailty

Answer 20

A state assocaited with low energy, slow walking speed and poor strength

or

A state of increased vulnerability to poor resolution of homeostasis after a stressor event

Question 21

What is the most common diagnositc test of frailty?

Answer 21

The 4m walking speed test

Question 22

Define Medicines Optimisation

Answer 22

An outcome focussed approach to safe and effective use of medicines that takes into account the patients values, perceptions and experience of taking their medication

Question 23

What are the 4 levels of medication review?

Answer 23

0 –> An opportunisitc review out of nowhere

1 –> Prescription review

2 –> Treatment review (with full patient notes)

3 –> Full review with patient, notes and prescription history

Question 24

In terms of medication reviews, what is the acronym SWAN?

Answer 24

Safety

Working well

Appropriate

National Guidance

Question 25

What are the **4 highest risk medications for ADRs**?

Answer 25

Antiplatelets Diuretics NSAIDs Anticoagulants

Question 26

What is **mARS**?

Answer 26

**modified Anticholinergic Risk Scale (mARS)** Assigns a score to medication (1-3), to see the total anticholinergic effect of one persons total medications

Question 27

What is the difference between a **criterion-based medication review and a judgement based approach**?

Answer 27

**Criterion-Based** --\> Can be applied with little/no clinical knowledge and low cost (Beers and STOPP/START) - Doesnt account for patient preference, and need to be updated frequently **Judgement-Based** --\> Focus on the patient (MAI and NOTEARS) - But is time consuming

Question 28

Define **Malnutrition**?

Answer 28

A state of nutrition in which a deficiency or excess of energy, protein and other nutrients causes measurable adverse effects on tissue/body form and function and clincal outcome

Question 29

Define **Cachexia**

Answer 29

A multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass that cannot fully be reversed and leads to progressive functional impairment

Question 30

Define **Sarcopenia**

Answer 30

The natural age-related reduction in skeletal muscle mass in the elderly **Primary** = natural **Secondary** = An extrinsic factor aggrevates the natural process (eg, malnutrition/lack of exercise/chronic malnutrition)

Question 31

Explain the **Malnutrition Carousel**

Answer 31

Question 32

How do you **identify malnutrition**?

Answer 32

Question 33

What is **Food First**?

Answer 33

**Improving an individuals nutritional intake with nourishing food and drinks** This could be done by selecitng more appropriate food (eg, a digestive over a rich tea) or by fortifying food

Question 34

When would a **daily multivitamin be suggested** for a person?

Answer 34

Those identified with a medium to high risk of on the FOOD MUST screening tool (1 or more)

Question 35

When are **Oral Nutritional Supplements (ONS)** used?

Answer 35

Patients with a **MUST score of 2 or more (high risk)**

Question 36

What things could be the **cause of the increase in polypharmacy**?

Answer 36

Ageing population More NICE guidlines (for prescribing...NOT deprescribing) Hospitals like to increase medications, but not stop many!

Question 37

What are some of the **barriers to deprescribing**?

Answer 37

Patient uncertainty of what will happen if the drug is discontinued Monitry incentives to over-prescribe Can be complex and time consuming (easier to just leave it!)

Question 38

What are the **7 steps of managing polypharmacy**?

Answer 38

Assess patient Define goals Identify medicines of concern Agree priorities for review Agree to start/stop/continue Communicate with other relevent people Monitor and adjust regularly

Question 39

What was the **Montgomery Ruling**?

Answer 39

Where a women with diabetes had a vaginal birth as the risks had not be outlines to her correctly, leading to the child having brain damage She won the case, with it being said that she wasnt given enough information to give her consent

Question 40

What is known as "**Crossing the Bridge**"?

Answer 40

Moving from the information gathering stage of the consultaiton to the management stage

Question 41

What is an **audit**?

Answer 41

Asks the question: "Are we actually doing what believe is the right thing, and in the right way?"

Question 42

What is a **formulary**?

Answer 42

The output processes to support the managed introduction, utilization or withdrawal of healthcare treatments within a local healthcare system, service or organisation Not just drugs!

Question 43

Explain the **traffic light system**

Answer 43

**Red** --\> Can only be started in secondary care **Amber** --\> Initiated by consulatants, but can then be prescribed by GPs (often with the use of shared-care agreements) **Green** --\> Can be used across both primary and secondary care Blue --\> Second-line treatments

Question 44

What is the role of the **Drugs and Therapeutics Committee**?

Answer 44

Review selected pharmaceutical products to assess their clinical value, safety and suitability for use in the health economy to guide all prescribers in primary and secondary care in using them appropriatly

Question 45

What is a **NICE TA**?

Answer 45

A technology appraisal done by NICE which requires the NHS to put the drug on their formularies within 3 months But it is still the local formualries choice on where the drug fits in...but must be on there somewhere!

Question 46

What is a **NICE STA, MTA and FTA**?

Answer 46

**STA** --\> A TA for a single drug or treatment **MTA** --\> A TA for multiple drugs/treatments for a single condition **FTA** --\> A fast track for drugs that offer substantial value for money, and so improve access to the drugs for those that need them. If it passes then the NHS must find funds for it within 30 days

Question 47

**Which chapter of the BCAP formulary is updated more often** than the normal 2 year period?

Answer 47

**Chapter 5 (Infections)** This is because of resistance and changes in practice

Question 48

What are the following **TEP** **ACP**

Answer 48

**TEP** --\> Treatment Escalation Plan - How far the patient is willing to be treated **ACP** --\> Advanced Care Plan - What procedures they are happy or not happy to have If the patient can concent however, their word is taken over the TEP/ACP!!

Question 49

What are the **6 different types of Bias**?

Answer 49

**Avaliability Bias** --\> Recalling a past case (eg, assuming a rare side effect has occured again) **Anchoring Bias** --\> Fixate on first impressions (eg, car sales) **Premature Closure Bias** --\> Decisions made on little evidence (B-blockers and bradycardia) **Framing Bias** --\> Being swayed by the phrasing (eg, 8 out of 10 live or 2 fail to live out of 10) **Representativeness Bias** --\> Assumption that as something resembles something else, that it is in fact that **Confirmation Bias** --\> Favouring information that confirms their beliefs/hypotheses (assuimg the insulin in your hand will be humalog as thats what the script says)

Question 50

What is the **criteria for monitoring for an adverse side effect**?

Answer 50

The effect is serious Simple test is avaliable Earlier detection is predictive That change in treatment could lead to a better outcome

Question 51

When are **drugs stopped**?

Answer 51

**Negative Outcome** --\> Adverse effect, renal function or hypertensiver patient falling over for example **Positive Outcome** --\> Things like pain relief falling below a certain threshold

Question 52

What are the **5 categories of causes of malnutrition**?

Answer 52

**Pschychological** (eg, depression, dementia, lack of interest of food) **Physiological** (eg, swallowing problems, pain, constipation) **Social** (eg, living alone, little money) **Increased nutritional need** (eg, infection, increased physical activity) **Nutrient loss** (eg, malabsorption, diarrhoea and vomiting)

Question 53

What are the **benefits of taking a bisphosphonate (for osteoporosis) for over 3 years**?

Answer 53

**Not much!!** If they are getting side effects or there is no real benefit to be seen, it may be sensible to stop it - Patient must be included in this decision however

Question 54

What is a **Significant Event Review (SER)**?

Answer 54

When a bad error occurs, people review it and sit down to discuss how they will respond to it, to prevent it from occuring again All NHS organisations will have policies on this

Question 55

What is the **righting reflex**?

Answer 55

The idea of hearing somebodies problem and then immediately trying to help them - Without getting as much information as possible first

Question 56

What are the **4 principles of medicines optimisation**?

Answer 56

Understand the patients experience Evidence based choice of medicines Ensure medicines use is as safe as possible Make medicines optimisation part of routine practice