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How Do We Keep Track of Medication Changes for Patients on Blister Packs?

Pharmacy blister pack changes arrive mid-cycle by phone, fax and email and are easy to miss. We build a change log and prep schedule for your MDS patients.

Updated 3 min readBy SpiderHunts Technologies

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Quick answer — TL;DR

Blister pack changes go wrong because they arrive through several channels in the middle of a cycle and depend on everyone remembering. We build one change log that every channel feeds into, a prep schedule for each patient's cycle, and a sign-off record showing each change was actioned.

Trays on the bench, a change on the phone

Your compliance pack patients are on four-week or weekly cycles, each with its own collection or delivery day. The trays for next week are part-made when the phone rings: a GP practice has changed a dose, or stopped something, or started something new. Someone writes it on a note and puts it in the patient's folder.

The next day a discharge letter arrives by email for another patient. A carer rings to say a tablet has been dropped. By Friday, the folder for that first patient has two notes in it and it is not obvious which is the latest.

Why changes are the risky moment

Making up trays is repeatable work. Changes are not. They arrive through the phone, email, fax, NHS mail, discharge letters, and new prescriptions, at any point in the cycle, and they may affect trays already made.

Each patient has their own cycle and their own paper folder or file. There is no single place showing which patients have a change pending and whether it has been actioned. The process relies on the person who took the call also being the person who makes up the trays, or on a note being read.

What missed or late changes cost

ProblemConsequence
Change noted but not seenA tray is made up to the old instructions
Trays already madeRework when a change arrives late in the cycle
No sign-off recordYou cannot show when a change was actioned
Prep dates in headsTrays made in a rush on the day they are due
Staff absenceOnly one person knows the state of each patient

What any change means clinically, and whether a tray needs remaking, is the pharmacist's decision. We make sure the change is in front of the right person at the right time.

A change log and prep schedule

  1. A patient list for everyone on compliance packs, with their cycle, prep day, collection or delivery day and any notes you keep.
  2. One change log. Every change, whatever channel it came from, is entered once with the date, source and a copy of the document if there is one. Emails can be forwarded straight into it.
  3. Status on every change: received, reviewed by pharmacist, actioned on the PMR, trays updated. Nothing drops off until all steps are ticked.
  4. A prep schedule showing which trays are due to be made each day, with a warning mark on any patient who has an open change.
  5. A cycle view for each patient so anyone covering can see what was done and what is pending.
  6. A weekly summary of changes by source, which helps when you talk to surgeries or care homes about how they send updates.

The PMR remains the record of the patient's medication. The change log is the tracking layer around it, so nothing arrives and gets forgotten.

Tray prep with nothing hiding in a folder

When the team starts on the day's trays, the prep schedule shows which patients have open changes, before anyone opens a blister. Changes taken on the phone by one person are visible to everyone. When the pharmacist signs off a change, there is a record of when and by whom.

Cover during holidays becomes easier too. Someone who does not normally run the trays can open the schedule and see exactly where things are.

Signs your tray process needs a change log

  • Changes are written on notes in patient folders
  • Trays have been made up before a change was seen
  • Only one or two people know the state of each patient's cycle
  • Discharge letters and emails arrive in different inboxes
  • You could not quickly show when a particular change was actioned

FAQ

Frequently asked questions

The questions readers ask us after this guide.

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Does this replace our PMR?

No. The PMR stays the medication record. The change log tracks the arrival and actioning of changes around it.

Can emails from surgeries go straight into the log?

Yes. A forwarding address or shared mailbox rule can create a log entry with the email attached.

Will it tell us whether a tray needs remaking?

No. That is a decision for the pharmacist. The log makes sure the change is seen before trays are made or sent.

Does it work for care home patients too?

Yes, although care homes usually have their own cycle, which we set up as a group.

Keep reading

More on Problems We Solve

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Tell us how your tray patients are managed

Tell us how many patients receive compliance packs, how changes arrive and how prep is scheduled. We will tell you where a change log would help and where your existing process already works.

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