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Introduction to Medicines, Poisons and Pharmacy Calls

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Introduction to Medicines, Poisons and Pharmacy Calls. Ruth Cheema ... NHS Direct Child Protection Policy. NHS Direct Adverse Incident Management Policy ... – PowerPoint PPT presentation

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Title: Introduction to Medicines, Poisons and Pharmacy Calls


1
Introduction to Medicines, Poisons and Pharmacy
Calls
For Health Advisors, Health Information Staff and
Nurse Advisors
  • Ruth Cheema
  • Medicines Information Pharmacist
  • Trent Medicines Information Service

2
Aim
  • To enable all staff answering Medicines, Poisons
    and Pharmacy calls to work within role
    competencies and fulfil them safely, reliably and
    effectively in this area of care.

3
Learning Outcomes
  1. Have an overview of NHS Directs Pharmacy and
    Medicines Services
  2. Have an overview of UK Medicines Information
    Services, National Poisons Information Service
    and Community Pharmacy Services
  3. Have a baseline knowledge for handling Medicines
    and Poisons Calls

4
Session Timetable
  • NHS Directs Pharmacy and Medicines Services
  • Workshop 1 Ethical Dilemmas
  • Overview of UK Medicines Information
  • Overview on National Poisons Information Service
  • Break
  • Overview of Community Pharmacy Services
  • Baseline Knowledge for handling Medicines Calls
  • Workshop 2 What is a Medicine?
  • What Next?

5
Session Timetable
  • NHS Directs Pharmacy and Medicines Services
  • Workshop 1 Ethical Dilemmas
  • Overview of UK Medicines Information
  • Overview on National Poisons Information Service
  • Break
  • Overview of Community Pharmacy Services
  • Baseline Knowledge for handling Medicines Call
  • Workshop 2 What is a Medicine?
  • What Next?

6
NHS Directs Pharmacy and Medicines
Services
  • Why learn about Pharmacy
    and Medicines?
  • Research from 2000 showed
  • 6 of all calls to NHSD are for advice about
    medicines
  • 40 of calls include advice about medicines

7
NHS Directs Pharmacy and Medicines Services
  • Medicine Calls may involve

Prescription-only Medicines (POM) Homeopathic preparations
Pharmacy Medicines (P) Food supplements and vitamins
General Sales List Medicines (GSL) Recreational drugs and drugs of abuse
Herbal remedies Steroids in sport
8
NHS Directs Pharmacy and Medicines Services
  • Is there a Policy?
  • Look in
  • NHS Direct National Policy for Handling Medicines
    Calls NP005

9
NHS Directs Pharmacy and Medicines Services

Definition of Medicine Calls Approved Reference Sources
Principles for Handling Medicines calls Record keeping and Documentation
(Poisons calls) Quality Assurance
Guidance for specific types of calls Training and Development
NP005 covers
10
NHS Directs Pharmacy and Medicines Services
NP005 Definition of Medicines
  • Any substance or article which is manufactured,
    sold, supplied, imported or exported for use
    wholly or mainly in
  • Treating or preventing disease
  • Diagnosing disease or status of a physiological
    condition
  • Contraception
  • Inducing anaesthesia
  • Temporarily or permanently affecting a
    physiological function in any way

11
NHS Directs Pharmacy and Medicines Services
  • Overview of the roles of different staff in
    handling medicines calls role competencies and
    limitations

Call Handlers/Health Advisors Information on access to medicines, repeat prescriptions, P4Q calls
Health information staff Medicines Information when no new or worsening symptoms
Nurse Advisors Medicines advice when new or worsening symptoms present
12
NHS Directs Pharmacy and Medicines Services
P4Quick Call
  • P4 Priority Quick Calls on access to pharmacy
    services and medicines e.g.
  • Emergency Hormonal Contraception
  • Information on missed contraceptive pills
  • Repeat medication
  • Access to medicines
  • do not need to be referred to Health Information.
  • Details in the Medicines handling Policy NP005

13
NHS Directs Pharmacy and Medicines Services
Other NHS Direct Policies
  • NP001 National Guidance for the Management of
    Frequent Callers
  • NP002 National Policy for the Referral of
    Callers with Mental Health Issues to
    Mental Health Helplines
  • NHS Direct FAQs regarding Protecting and Using
    Patient Information
  • NHS Direct Child Protection Policy
  • NHS Direct Adverse Incident Management Policy
  • NHS Direct Complaints and Feedback Policy
  • NHS Direct Third Party Calls Policy

14
NHS Directs Pharmacy and Medicines Services
Compulsory checks for new/active or recurrent
symptoms
Are you calling about an injury or a new or
worsening health problem? 
15
NHS Directs Pharmacy and Medicines Services

Risk Factors in taking medicines calls
Misunderstanding what the caller said Omitting relevant information sources
Missed symptoms Working outside level of competency
Incomplete background information Caller doesnt understand the answer
Incomplete documentation Inaccurate documentation
16
Session Timetable
  • NHS Directs Pharmacy and Medicines Services
  • Workshop 1 Ethical Dilemmas
  • Overview of UK Medicines Information
  • Overview on National Poisons Information Service
  • Break
  • Overview of Community Pharmacy Services
  • Baseline Knowledge for handling Medicines Calls
  • Workshop 2 What is a Medicine?
  • What Next?

17
Ethical Dilemmas
  • Medicines calls that may lead to ethical dilemmas
  • Age of caller
  • Third party calls
  • Refusal of another HCP to supply a medicine
  • Caller not wishing to disclose information to Dr
  • Wrong information given to caller by HCP
  • Caller taking a higher dose than prescribed
  • Caller wants information about how to obtain a
    medicine that is of dubious worth
  • Caller prescribed two interacting medicines

18
Ethical Dilemmas
  • I found a tablet.
  • My G.P. says this. but Ive read the other.
  • Does heroin interact with..?
  • Could my partners tablets cause?

19
Ethical Dilemmas General Guidance
  • All the published information sources that you
    use are in the public domain.
  • Instinct You may have to do what seems right to
    you.
  • You do not have to answer everything that you are
    asked!
  • Document carefully everything that you do
  • There are often no right answers .
  • Give yourself thinking time
  • Second opinion try to speak to a colleague or to
    the Medicines Information Centre.
  • Conflicts try not to get caught up in patient
    conflicts with other professionals.

20
Workshop 1 Ethical Dilemmas
A man asks how long cocaine stays in the body. He
used some cocaine at the weekend but is due to
have a drug test tomorrow. What advice would you
give?
A woman says she has found some medicines in her
sons room. She reads the labels - lamivudine,
zidovudine saquinavir. Can you tell her what
they are for? Would your answer be different if
the call was from his wife?
21
Session Timetable
  • NHS Directs Pharmacy and Medicines Services
  • Workshop 1 Ethical Dilemmas
  • Overview of UK Medicines Information
  • Overview on National Poisons Information Service
  • Break
  • Overview of Community Pharmacy Services
  • Baseline Knowledge for handling Medicines Calls
  • Workshop 2 What is a Medicine?
  • What Next?

22
Overview of UK Medicines Information
  • UKMi - supports MI needs of NHS health
    professionals
  • gt½ million enquiries 2005
  • 16 regional 260 local centres
  • Specialist services - pregnancy, breastfeeding,
    liver disease
  • Training, websites, QA, drug reviews

23
Overview of UK Medicines Information
Your Medicines Information Service
Your team photo
24
Overview of UK Medicines Information
  • Staff
  • Pharmacists
  • Pre-registration students
  • Secretarial support
  • Service to NHS Direct
  • Complex medicines calls
  • MI skills training
  • Quality Assurance
  • National work
  • 9am - 5.00pm
  • Your MI phone number

25
Overview of UK Medicines Information
  • Refer to the UKMi Service if
  • You need interpretation of call
  • You have no information or it is unclear
  • It is a complex call
  • Not within your competency

Name, hours and contact details of your Regional
MI Service
26
Overview of UK Medicines Information
Complex Calls
  • Caller taking 3 or more prescription medicines
  • Dose(s) outside the normal range
  • Unlicensed use of medicine or use of unlicensed
    medicine
  • High risk medicines e.g. aminophylline,
    carbamazepine, digoxin, lithium, methotrexate,
    phenytoin, theophylline, warfarin
  • Medicines in pregnancy or breastfeeding

27
Session Timetable
  • NHS Directs Pharmacy and Medicines Services
  • Workshop 1 Ethical Dilemmas
  • Overview of UK Medicines Information
  • Overview on National Poisons Information Service
  • Break
  • Overview of Community Pharmacy Services
  • Baseline Knowledge for handling Medicines Calls
  • Workshop 2 What is a Medicine?
  • What Next?

28
Overview of National Poisons Information
Service
  • 24 hour, UK wide clinical toxicology service for
    healthcare professionals
  • Staffed by Poisons Information Specialists,
    Nurses, Pharmacists, Physicians
  • Provide information advice on diagnosis,
    treatment and management of poisoning

29
Overview of National Poisons Information
Service
  • Five poisons centres
  • Belfast, Cardiff, Birmingham, Edinburgh,
    Newcastle
  • One national number 24/7
  • 0870 600 6266

30
Overview of National Poisons Information
Service
TOXBASE
At NHS Direct used by NAs only
  • Primary Clinical Toxicology database of NPIS
  • Available to healthcare professionals only
  • Contains colour-coded NHS Direct advice boxes
  • Updated daily
  • Low Toxicity Poster substances safe if ingested

31
Overview of National Poisons Information
Service
TOXBASE
Provides information on toxicity and management
of acute poisoning for over 14,000 products
search by brand name or type of product
Pharmaceuticals Household other Commercial Products
Industrial Chemicals Plants
Agricultural Chemicals Snakes
Veterinary Products Insect Bites
32
Session Timetable
  • NHS Directs Pharmacy and Medicines Services
  • Workshop 1 Ethical Dilemmas
  • Overview of UK Medicines Information
  • Overview on National Poisons Information Service
  • Break
  • Overview of Community Pharmacy Services
  • Baseline Knowledge for handling Medicines Calls
  • Workshop 2 What is a Medicine?
  • What Next?

33
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34
Session Timetable
  • NHS Directs Pharmacy and Medicines Services
  • Workshop 1 Ethical Dilemmas
  • Overview of UK Medicines Information
  • Overview on National Poisons Information Service
  • Break
  • Overview of Community Pharmacy Services
  • Baseline Knowledge for handling Medicines Calls
  • Workshop 2 What is a Medicine?
  • What Next?

35
Overview of Community Pharmacy Services
36
Overview of Community Pharmacy Services
10 facts about Community Pharmacy
6 million people visit a community pharmacy every day.
94 population use the local pharmacies at least once a year.
Community pharmacy could manage up to 8 of adult attendances to AE.
80 repeat prescriptions could be handled by community pharmacists, saving 2.7 million hours of GP/practice time.
NHS could save 380 million/year if 1 in 4 people consulted their pharmacist about minor ailments instead of the GP.
37
Overview of Community Pharmacy Services
10 facts about Community Pharmacy
30 PCTs developing schemes to provide patients treatment for minor ailments through pharmacies.
In 2002, the NHS medicines bill was 8 billion, 250 more than in 1990.
In 2002, 712 million prescription items were dispensed, 50 more than 1990.
75 GPs say pharmacists should be able to prescribe certain medicines and offer extended advisory services.
In one study, 66 of patients did not require all prescription items to be dispensed.
38
Overview of Community Pharmacy Services
New Contract
  • Started 1st Apr 2005, monitoring delayed until
    Oct
  • Benefits
  • Improve access to community pharmacy
  • Expand range of services provided
  • Make better use of pharmacist skills
  • Help reduce workload pressures on GPs
  • 3 levels of service Essential, Advanced, Enhanced

39
Overview of Community Pharmacy Services
Essential services
  • Dispensing
  • Patient records
  • Compliance support
  • Electronic transfer of prescriptions
  • Repeat dispensing
  • Pharmacist managed repeats
  • Disposal of unwanted medicines
  • Health promotion
  • 6 campaigns / year
  • Signposting
  • Support for self care
  • Clinical Governance

40
Overview of Community Pharmacy Services
Advanced Services
  • Optional
  • Accreditation to provide
  • Medicines Use Review
  • Long-term conditions
  • Identified by PCT
  • Report to patient and GP
  • Prescription Intervention
  • Response to specific issue
  • Report to patient and GP

Accreditation
Pharmacist has passed a competency test Patient and pharmacist can sit down together Talk normally without being overheard Private consultation area
41
Overview of Community Pharmacy Services
Enhanced Services
  • PCTs may commission to meet local need
  • May implement recognised services or develop own
    initiatives

Suggested Enhanced Services Suggested Enhanced Services
Minor Ailments Smoking Cessation Supervised Administration of Medicines Anticoagulant Monitoring Needle Exchange Schemes Care Home Support Emergency Hormonal Contraception Schemes Medicines Review
42
Overview of Community Pharmacy Services
Staff in a community pharmacy
Sales assistants Trained to work in shop but not to sell or advise on medicines
Counter assistants Trained to sell and advise on medicines supervision by pharmacist
Dispensing technicians Trained to dispense Rx all checked by pharmacist
Pharmacist Responsible for all sales and Rx of medicines
By law a pharmacy is not a pharmacy if pharmacist
not present
43
Overview of Community Pharmacy Services
Access hours
  • Monday Saturday standard shop hours
  • OOH system to cover evenings and Sunday by local
    agreement

44
Overview of Community Pharmacy Services
Out of Hours (OOH) Provision
Check NHS.uk for details of local arrangements
for OOH service Look on NHS Direct online under
Common Health Problems for Emergency Supply of
medicines from a community pharmacy
45
Overview of Community Pharmacy Services
Emergency Supply by a pharmacist charge to
patient
  • Pharmacist must interview the person
  • Immediate need and impractical to obtain a
    prescription
  • Previously prescribed for the person
  • Dose appropriate for the person
  • Supply up to 5 days except
  • Insulin, ointment, cream, drops, inhaler
    smallest pack
  • Oral contraceptive - a full cycle
  • Antibiotic - a full course of treatment
  • Do not supply a Controlled Drug
  • Except phenobarbitone for epilepsy

46
Overview of Community Pharmacy Services
NHS Prescription Charges
  • 6.65 for each NHS Prescription
  • Irrespective of cost to NHS of medicine
  • Irrespective of quantity
  • Same drug and form is one charge
  • Various charges for combination products
  • Pre-payment certificates forms from community
    pharmacies

47
Overview of Community Pharmacy Services
Exemptions from prescription charge
  • Aged under 16
  • Aged 16, 17 or 18 years in full time education.
  • Aged 60 or over.
  • Has a Maternity Exemption certificate.
  • Has a Medical Exemption certificate.
  • Has a War Pension exemption certificate.
  • Has a Prescription Prepayment certificate.
  • Named on a NHS Charge certificate (HC2).
  • Prescribed free of charge oral contraceptives.
  • Gets Income Support or Income Based Jobseekers
    Allowance.
  • Entitled to / named on, NHS Tax Credit Exemption
    certificate.
  • Partner gets Pension Credit Guarantee Credit.

.
48
Overview of Community Pharmacy Services
Confidentiality
  • Code of Ethics Pharmacist must treat patients
    with confidentiality
  • Data Protection Act Includes paper and
    computerised patient medication records
  • Caldicott Principles Good practice for using
    patient information in the NHS
  • Advanced Services Private consultation area

49
Overview of Community Pharmacy Services
  • Patient demographics
  • Medication dispensed
  • Drug brand/formulation
  • Strength
  • Quantity
  • Date
  • Special Notes
  • Counselling given
  • No clic-locks
  • Allergies

Patient Medication Records
50
Overview of Community Pharmacy Services
  • NHS Rxs on PMR
  • Private Rxs - in bound book or on PMR
  • Controlled drugs obtained or supplied - in bound
    book

Record Keeping
  • Checks by
  • RPSGB inspector
  • Superintendent Pharmacists
  • Police

51
Overview of Community Pharmacy Services
Emergency Hormonal Contraception (EHC)
  • Pharmacists may
  • Sell EHC (cost to patient) subject to certain
    restrictions e.g.age of patient
  • Supply EHC (free to patient) subject to
    pharmacist training and according to local
    guidelines (PGDs)

52
Overview of Community Pharmacy Services
  • Existing arrangements - prescriptions for oxygen
    dispensed at community pharmacy
  • From 2006 new arrangements in place
  • Patients will receive oxygen directly from
    supplier

Oxygen

53
Session Timetable
  • NHS Directs Pharmacy and Medicines Services
  • Workshop 1 Ethical Dilemmas
  • Overview of UK Medicines Information
  • Overview on National Poisons Information Service
  • Break
  • Overview of Community Pharmacy Services
  • Baseline Knowledge for handling Medicines Calls
  • Workshop 2 What is a Medicine?
  • What Next?

54
Baseline Knowledge for handling Medicines Calls
What is a Medicine?
Active Ingredient or Drug Excipients
vehicle, bulking agent, tablet coating, capsule
shell, colours, flavouring, stabiliser, pH
adjuster Form tablet, capsule,
suppository, eye drops, cream, patch, inhaler,
injection ..
55
Baseline Knowledge for handling Medicines Calls
Naming medicines
Generic Brand
Amoxicillin Amoxil
Salbutamol Ventolin
Fluoxetine Prozac
Omeprazole Losec
Mefloquine Lariam
56
Baseline Knowledge for handling Medicines Calls
Naming medicines
rINN - Internationally used naming system
introduced in June 2004
British Approved Name (BAN) Recommended International Non-proprietary Name (rINN)
Amoxycillin Amoxicillin
Dothiepin Dosulepin
Frusemide Furosemide
Lignocaine Lidocaine
57
Baseline Knowledge for handling Medicines Calls
Legal classification of medicines
General Sales List GSL May be sold in general shops e.g. Paracetamol
Pharmacy Only P May be sold in a pharmacy but not a general shop e.g. Zantac
Prescription Only POM May only be supplied on prescription e.g. Amoxicillin
58
Baseline Knowledge for handling Medicines Calls
Controlled Drugs (CDs)
Misuse of Drugs Act 1971 Controlled Drugs
harmful when misused. Act prohibits production,
supply or possession Post Shipman - CD
regulations strengthened eg returning CDs
Class A Heroin, LSD, ecstasy, morphine, remifentanil, Class B if injections
Class B Amphetamines, barbiturates, codeine, pentazocine, pholcodine
Class C Anabolic steroids, cannabis, growth hormone, clenbuterol
59
Baseline Knowledge for handling Medicines Calls
Marketing Authorisation Product Licence
Issued by Medicines Healthcare Products
Regulatory Agency
www.mhra.gov.uk
Product licenses granted if three questions have
been fully answered by manufacturer - Safety,
Quality, Efficacy
60
Baseline Knowledge for handling Medicines Calls
Marketing Authorisation Product Licence
  • Key aspects in Summary of Product Characteristics
    (SPC) and Patient information leaflet (PIL)
    www.medicines.org.uk Large print and Braille PILs
    to be available
  • Prescribing within the product licence is the
    responsibility of the doctor
  • Patient must give informed consent if medicine is
    unlicensed or used off label

61
Workshop 2 What is a Medicine?
Look at the sample packs of medicines. Can you
find.?
  • The brand name of the product
  • The name of the active ingredient
  • The strength of the active ingredient
  • The Product Licence number
  • The expiry date
  • The name of the manufacturer
  • The legal category
  • The batch number
  • The dosage form

62
Baseline Knowledge for handling Medicines Calls
Unlicensed Medicines
  • Off Label
  • UK product licence but being used for an
    indication / at a dose / by a route not in the
    licence
  • No Licence
  • No UK product licence
  • Methotrexate for asthma and lupus
  • Sodium valproate for prevention of migraine
  • Thalidomide
  • Melatonin
  • Most herbal products

63
Baseline Knowledge for handling Medicines Calls
Black Triangle medicines
  • Newly licensed
  • Monitored intensively by Commission for Human
    Medicines (CHM) which reports to MHRA
  • Black triangle status usually reviewed after 2
    years

64
Baseline Knowledge for handling Medicines Calls
Yellow Card Reporting Scheme
  • NEWER DRUGS
  • VACCINES (?)
  • All ADRs even if
  • Not certain that drug has caused it
  • Reaction well known
  • Other drugs at same time
  • ESTABLISHED DRUGS
  • VACCINES
  • All serious ADRs
  • Fatal, life threatening or disabling
  • Prolonged hospital stay
  • Even if well known

65
Baseline Knowledge for handling Medicines Calls
Patient reporting to Yellow Card Scheme
  • Pilot scheme launched Jan 2005
  • Patients can report suspected adverse effects
  • www.yellowcard.gov.uk
  • Patient report forms from 4000 GPs in pilot or
    MHRA
  • Help MHRA understand the patient experience and
    perspective of suspected adverse effects
  • Patients can view anonymous data on website

66
Baseline Knowledge for handling Medicines Calls
Medicines that may not be prescribed in the NHS
  • Known as the Black List
  • Pricing Prescription Authority (PPA) will not
    reimburse dispensing cost.

67
Baseline Knowledge for handling Medicines Calls
Borderline substances
  • Certain foods considered medicines in specific
    conditions.
  • Cost of dispensing reimbursed only if GP has
    endorsed script ACBS

ACBS e.g.Wysoy for milk protein sensitivity
68
Baseline Knowledge for handling Medicines Calls
Complementary Medicines
  • Homeopathy

Herbal Medicine
Safe to use with conventional medicines
May interact with conventional medicines
69
Baseline Knowledge for handling Medicines Calls
Food supplements
  • In the UK, herbal products are either foods or
    medicines.
  • New legislation from August 2005 placing stricter
    controls on the levels of vitamins and minerals
    in food supplements.

70
Baseline Knowledge for handling Medicines Calls
Who can prescribe medicines?
Doctor BNF
Dentist Dental Formulary
District Nurse / Health Visitor qualified as a Nurse Prescriber Nurse Prescribers Formulary
Nurse / Midwife qualified as an Extended Formulary Nurse Prescriber Nurse Prescribers Extended Formulary
71
Baseline Knowledge for handling Medicines Calls
Supplementary Prescribing
  • Voluntary partnership between doctor/dentist and
    supplementary prescriber to implement a clinical
    management plan with the patients agreement.
  • Prescribe all GSL, POM and CDs within the
    clinical management plan.
  • Pass approved training.

Currently Authorised Proposed
Nurse Midwife Pharmacist Physiotherapists Radiographers Chiropodists, Optometrists
72
Baseline Knowledge for handling Medicines Calls
Patient Group Direction (PGD)
  • New legislation to improve access to medicines
  • No individual prescription but Dr signs
    instructions for Specific Patient Group
  • Named health professional authorised to
  • Supply a pre-labelled, fixed quantity medicine
    or
  • Administer fixed quantity medicine

Supply by PGD
Casualty Minor Injuries Clinic Walk-In Centre Family Planning Clinic Genito-Urinary Clinic Ante-Natal Clinic Diabetic Clinic and more
73
Baseline Knowledge for handling Medicines Calls
Adverse Drug Reactions - at risk patient groups
  • Pregnancy
  • Breastfeeding
  • Infants/children
  • Elderly
  • Patients on high risk medicines
  • Renal problems
  • Liver problems

74
Baseline Knowledge for handling Medicines Calls
Drug Interactions
One drug modifies the effect of a second drug
  • More likely if taking several medicines
  • Interactions can occur between conventional
    medicines and

Other conventional medicines Foods
Herbal medicines Alcohol
Illicit/street drugs Food supplements
75
Baseline Knowledge for handling Medicines Calls
Primary resources for Medicines Calls
not in CAS system
76
Baseline Knowledge for handling Medicines Calls
  • Other support for medicines calls

NHS Direct in-house resources Health Information Specialists Health Information library
UK Medicines Information. Your local centre is Name Phone number.
77
Session Timetable
  • NHS Directs Pharmacy and Medicines Services
  • Workshop 1 Ethical Dilemmas
  • Overview of UK Medicines Information
  • Overview on National Poisons Information Service
  • Break
  • Overview of Community Pharmacy Services
  • Baseline Knowledge for handling Medicines Calls
  • Workshop 2 What is a Medicine?
  • What Next?

78
What Next?
More practice and hands-on training
All Nurse Advisors 6 hours Handling Medicines Calls
All Health Information staff 6 Hours Handling Medicines Calls 3 Hours Oral contraception
79
What Next?
..and More
  • Further skills sessions for HIAs and NAs
  • Medicines in Pregnancy and Breastfeeding
  • Oral Contraception and EHC
  • Travel Medicines
  • Complementary and Alternative Medicines
  • eBNF and eMC further skills
  • Immunisation

80
Learning Outcomes
  • Have an overview of NHS Directs Pharmacy and
    Medicines Services
  • Have an overview of UK Medicines Information
    Services, National Poisons Information Service
    and Community Pharmacy Services
  • Have a baseline knowledge for handling Medicines
    and Poisons Calls
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