McKenna's Pharmacology for Nursing, 2e

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C H A P T E R 6  Challenges to effective drug therapy

to be used by Australians and visitors from a number of countries where there are reciprocal arrangements, including New Zealand, the Republic of Ireland and the United Kingdom. Within the scheme, there exists a safety net which is set each year. Upon reaching the safety net for that year, an individual or family is eligible to receive subsequent medicines at either a concessional rate or for free, depending on their circumstances. Quality use of medicines The Australian Government, through the National Medicines Policy, operates the Quality Use of Medicines (QUM) program. The program is underpinned by four main principles. Judicious use requires that medicines are used when appropriate and after all options have been considered. Secondly, there should be appropriate use of medicines to treat the condition with all factors, such as risks and costs, considered. Thirdly, safe use of medicines is required to avoid misuse, while efficacious use requires that medicines used have beneficial health outcomes. Nurses and midwives play a central role in enacting this program as they are often the closest to people and their medicines. In New Zealand, the New Zealand Medicines and Medical Devices Safety Authority collects infor- mation on the safety and quality of medicines and vaccines through a variety of sources. These activities are called pharmacovigilance. There are different phar- macovigilance centres in New Zealand that nurses and midwives need to be familiar with. The Centre for Adverse Reaction and Monitoring Centre (CARM) in Otago, the Intensive Medicines Monitoring Programme (IMMP), the Medicines Adverse Reaction Committee (MARC) and a new scheme called the Medicines Moni- toring (M2). This scheme’s aim is to highlight potential safety issues identified from reports of suspected adverse medicine reactions sent to CARM, to stimulate further reports and to increase the information on these poten- tial safety signals. Home care The home care industry is one of the most rapidly growing responses to the changes in costs and medical care delivery. People now routinely go home directly from surgery with the responsibility for changing their own dressings, assessing wounds and monitoring their recovery. People are also being discharged from hos- pitals because the funded hospital days allowed for a particular diagnosis have run out. These people may be responsible for their own monitoring, rehabilitation and drug regimens. At the same time, the population is ageing and may be less accepting of all of this respon- sibility. Community nurses and midwives as well as hospital in the home programs are taking over some of the responsibilities that used to be handled in hospitals.

The responsibility for meeting the tremendous increase in teaching needs of people frequently resides with the nurse or midwife. People need to know exactly what medications they are taking (generic and brand names), the dose of each medication and what each is supposed to do. They also need to know what they can do to alleviate some of the adverse effects that are expected with each drug (e.g. small meals if gastro­ intestinal upset is common, use of a humidifier if secretions will be dried and make breathing difficult); which OTC drugs or alternative therapies they need to avoid while taking their prescribed drugs; and what to watch for that would indicate a need to call the health- care provider. With people who are taking many drugs at the same time, this information should be provided in writing, in language that is clear and understanda- ble. Many pharmacies provide written information with each drug that is dispensed, but trying to organise these sheets of information into a usable and understandable form is difficult for many people. The nurse or midwife often needs to sort through the provided information to organise, simplify, and make sense of it for the person. The cost of dealing with toxic or adverse effects is often much higher, in the long run, than the cost of the time spent teaching and explaining things. The projections for trends in healthcare indicate even greater expansion of home healthcare provision, with hospitals being used for only the most critically ill people. The role of the nurse and midwife in this home health system is crucial—as teacher, assessor, diagnosti- cian and advocate. Cost considerations Despite the insurance cover a person may have for prescription medications, it is often necessary for the healthcare provider to choose drug therapy based on the costs of the drugs available. With more and more of the population reaching retirement age and depend- ing on a fixed income, costs are a real issue. Sometimes this may mean not selecting a first-choice drug but settling for a drug that should be effective. People who take antibiotics must be reminded to take the full course and not to stop the drug when they feel better. People may be tempted to stop taking the antibiotic in order to save the remaining pills for the next time they feel sick and to also save the cost of another healthcare visit and a new prescription. This practice has contributed to the problem of resistant bacteria, which is becoming more dangerous all the time. People also need to be advised not to split tablets in half unless specifically advised to do so. Some drugs can be split, and it is cheaper to order the larger size and have the person cut the tablet. Some people think that by cutting the drug in half they will have coverage for twice the time allowed by the prescription and will