A consultation into the standardisation of pack sizes of oral nutritional supplements (ONS) has highlighted the potential for prescribing errors, patient safety risks, increased waste and cost, and increased workload for community pharmacists under the current system.

The Advisory Committee on Borderline Substances (ACBS) has decided to explore these concerns before recommending any action on standardising volume size, it said in a consultation response published today.

Work to improve communication of prescribing practice

Consultation responses highlighted 'issues for communication between the dietitian requesting the prescription, the prescribing GP and the dispensing pharmacist'.

Dieticians expressed frustrations with an inability to prescribe products themselves, instead opening up the possibility for GPs to misinterpret prescribing directions, which was exacerbated by inconsistent volumes and similar product names.

A major issue highlighted by several responses was inconsistent measurements being used across systems, such as the use of 'millimeters' compared to 'sachets' or 'bottles', which can result in over-prescribing or inadequate quantities for a therapeutic dose.

And one GP respondent said that 'prescribing errors due to the odd numbers/volumes involved' leads to 'increased workload for the GP practice and community pharmacy and delay for the patient'.

Responses also highlighted issues due to 'an overwhelming amount of product options with similar names'.

ACBS also suggested that the current way nutrition borderline substances are categorised within the BNF 'has the potential to exacerbate inappropriate selection and prescription'.

While it had originally proposed standardising volumes of ONS products, following the consultation it said that more work was needed to explore further issues raised by the consultation.

Lack of education and training

Consultation responses also highlighted evidence of 'clinicians misunderstanding the meaning of standard adult ONS products', as well as a lack of knowledge about each other's roles, ACBS said.

For instance, 34% of dietitian respondents thought that community prescribing errors related to adult ONS were caused by GP error due to inadequate GP knowledge, while 30% suggested that GPs were selecting an incorrect product from the system.

And one pharmacist respondent highlighted a lack of training on ONS, saying that during their 4-year degree they had only  experienced 'a single 2-hour workshop on ONS and nutrition', with no further training courses on the subject 'despite it being a community pharmacist’s job to supply these products'.

Another respondent said: 'Prescribers in primary care generally have very little understanding of ONS. Prescriptions are often left to run long after they should have been stopped. Waste is significant...'

ACBS said it would work with stakeholders to consider the role of dietitians in primary care, determine how knowledge and communication issues might be addressed, and explore reported problems with prescribing systems and ONS.

Patient safety audit proposed

Reponses also raised concerns about patient safety incidents being caused by inappropriate ONS prescribing, such as a product with a similar name being prescribed even though it had the wrong nutritional profile for the patient.

NHS England and the Optimising Nutrition Prescribing Specialist Group of the British Dietetic Association have agreed to audit the scale and nature of patient safety incidents, the consultation response revealed.

Results will be shared 'by autumn 2024', and the ACBS will then consider whether to advise on changes, the response suggested.

Last year, pharmacy bodies spoke out against an increasing number of medicine recalls and notifications that pharmacy teams were having to deal with.