6 and 1.2mmol/liter [BNF, 1988]. In 2004 the Quality and Outcomes Framework (QOF) was initiated as part of the General Medical Services Contract. The QOF is a voluntary incentive scheme for primary care. It contains groups of indicators against which practices are scored according to their level of achievement [The Information Centre for Health and Social Care, 2012]. Within the QOF section on mental health, practices are scored for the percentage of patients on lithium with a record of serum creatinine and thyroid stimulating hormone (TSH) within the preceding 9 months, a record of lithium levels in the therapeutic range within the previous 4 months

and a Inhibitors,research,lifescience,medical body mass index (BMI) recorded in the past 15 months [The Information Centre for Health and Social Care, 2012]. NICE bipolar guidance states Inhibitors,research,lifescience,medical that, during maintenance treatment with lithium, a serum lithium level should be taken every 3 months, renal and thyroid function tests should be completed every 6 months (more often if there is evidence of impaired renal function), Inhibitors,research,lifescience,medical and weight, BMI or waist circumference should be measured annually [NICE, 2006]. The BAP guideline recommends that renal and thyroid function are tested every 12 months, with lithium levels checked every 3–6 months in people on a stable dose [BAP, 2009]. In December 2009 the National

Patient Safety Agency (NPSA) released a patient safety alert to improve the safety of lithium therapy [NPSA, 2009]. This focused on regular monitoring in line with NICE guidance; reliable communication systems for blood test results; appropriate verbal and written Inhibitors,research,lifescience,medical information provided to patients and systems are in place to identify and deal with potential interactions with lithium therapy [NPSA, 2009]. Lithium management in Norfolk Following a Selleckchem Tanespimycin series of clinical incidents in primary care regarding lithium toxicity, concerns were raised at Norwich Primary Care Trust that there was not a consistent Inhibitors,research,lifescience,medical approach to lithium monitoring across Norfolk. Data were extracted from the Norfolk and Norwich University Hospital pathology system from

October 1999 to October 2000. From a total of 1457 people with lithium levels recorded within this year, 32.6% had only one level, 54.3% had one or two levels, 45.6% had three or more levels, and 29.4% had four or more no levels [Holmes, 2005]. By May 2000 a pharmacy-led prescribing group had conceived the idea of a Norfolk-wide lithium register and database to help minimize the potential for future clinical incidents relating to lithium prescribing and monitoring. The lithium database was first implemented in May 2002 and complete rollout across Norfolk occurred by 2004 [Holmes, 2005]. For the successful implementation of this database there were two issues surrounding lithium prescribing and monitoring which needed to be addressed.