Reducing the risk of clozpine patient harm by correcting summary care records

Following the introduction of pharmacy-led clozapine clinics within Lincolnshire Partnership NHS Foundation Trust, pharmacy staff began carrying out medicines reconciliation for all patients. This identified that some summary care records (SCRs) did not list clozapine at all, showed additional antipsychotic medication prescribed by their GP and/or highlighted patients prescribed high dose combined antipsychotics (with no indication if this was intentional or not).

Given the strict monitoring and registration requirements for clozapine due to serious side effects and drug interactions, this was deemed a potential risk to patient care if GPs were not aware their patient’s were taking clozapine.

This potential risk was escalated to the Trust’s DTC and Patient Safety & Experience Committee meetings and placed on the Trust corporate risk register. A Continuous Quality Improvement (CQI) approach was taken and initiated.


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