Jayne Agnew, Consultant Pharmacist for Older People at Southern Health and Social Care Trust, and Dr Jen Stevenson, Lead Pharmacist at Guy’s and St. Thomas’ NHS Foundation Trust (@JenMStevenson – X and Blue Sky), explore the hidden risks associated with Multicompartment Compliance Aids (MCAs), also known as blister packs or dosette boxes.
The tragic death of Mrs. Sewa Kaur Chaddha, 82, underscores the risks. Mrs. Chaddha died after mistakenly taking her husband’s medications, including diabetic medicines, which caused severe hypoglycaemia. Both sets of medications were in identical MCAs, with only slight label differences, a mistake that went unnoticed and contributed to her death. The coroner’s Prevention of Future Deaths Report highlighted this as a contributing factor.
MCAs are intended to assist medication management but can cause a range of significant problems as we will illustrate through the case of ‘Eva’.
Eva, 78-years-old, lives with heart failure and multiple conditions. Eva regularly missed doses, prompting her daughter to request an MCA. The clinician agreed, but was this the best solution? Many people, including healthcare professionals, believe MCAs are a silver bullet for medication management. However, medication adherence is influenced by multiple factors, as outlined in the Capability, Opportunity, Motivation (COM-B) model of behaviour change. While MCAs may help with limitations in physical or cognitive capability, they do little to address motivational barriers, such as concerns about side effects, or Opportunity factors like patient/clinician relationships.
The Reluctance of the Pharmacist
Community pharmacists often face pressure to provide MCAs, even when their appropriateness is unclear. In Eva’s case, the pharmacist felt compelled to supply the MCA, despite doubts, because it was requested by another healthcare professional. Furthermore, the lack of funding for MCAs puts a strain on community pharmacies, and pharmacists often lack the necessary information about evaluation of the effectiveness of MCAs. There is no standardised process for evaluating whether an MCA is the right choice, though guidelines are available from NHS Specialist Pharmacy Service and the Royal Pharmaceutical Society (RPS).
The Need for a Thorough Assessment
Before implementing an MCA, a thorough assessment is essential. This should consider the reasons for non-adherence, whether the medications are still appropriate, and how the MCA will fit into overall medication management e.g. additional oral medications are often supplied outside of the MCA1. In Eva’s case, her risedronate and calcium were not included in the MCA, leading to confusion about her regimen. Also, she used to take her levothyroxine 30 minutes before breakfast, as instructed - should she now take all her other morning tablets at this time? What should she do on the day she takes her bone tablet, which needs to be taken before other medicines and food?
Stability and Wastage
Medicines are tested for stability in their original packaging, not in MCAs. The RPS recommends that medicines should not remain in MCAs for longer than eight weeks, with the Medicines in Compliance Aids Stability Tool providing further guidance on suitability.
MCAs contribute to pharmaceutical waste and increase workload for both community pharmacies and GPs, especially when prescriptions change, and so new MCAs require issuing. Outdated MCAs must be disposed of as pharmaceutical waste at high environmental costs2,3. This is particularly concerning during medicine shortages where returned medicines can’t be reused.
The Challenge of Medication Ordering
Eva stopped receiving risedronate and calcium, assuming they had been discontinued, but as these medications were not included in her MCA they were overlooked. MCAs are often on repeat ordering, while medications outside the MCA are not, leading to potential gaps in treatment.
The Role of Patient Empowerment
MCAs can disempower patients. The dose Eva ‘regularly missed’ was her furosemide. She would skip it when going out due to fear of incontinence. She became anxious when she couldn’t identify it and stopped leaving the house because she couldn’t differentiate the tablets. Would it have been simpler to take the furosemide in the afternoon, or skip it, as she had done before? This highlights that MCAs may hinder patients’ understanding of their medication regimen.
A Holistic Approach to Medication Management
MCAs should not be seen as a universal solution for non-adherence. A holistic approach to medication management is essential. A comprehensive assessment is needed to identify the root causes of medication challenges. All aspects of a patient’s medication regimen, including the involvement of others in the household and how medications outside the MCA are managed, must be considered. A holistic approach ensures that interventions are appropriate, effective, and tailored to each patient’s needs.
In conclusion, while MCAs can be useful, they must be implemented with caution. A personalised approach to medication management, where patients and carers are empowered to manage medications safely, is key to improving adherence and preventing tragic incidents like Mrs. Chaddha’s death.
1. David Counter, Derek Stewart , Joan MacLeod , James S McLay. Multicompartment compliance aids in the community: the prevalence of potentially inappropriate medications. Br J Clin Pharmacol. 2017 Jan 31;83(7):1515–1520. doi: 10.1111/bcp.13220
2. Rizan C, Bhutta M, Reed M, Lillywhite R. The carbon footprint of waste streams in a UK hospital. Journal of Cleaner Production, vol 286, 1 March 2021, 125446.
3. Estates Returns Information Collection report (ERIC) 2019/20
