Transcript How to Prescribe Safely

Prescribing Safely
Kevin Gibbs
Pharmacy Manager: Clinical Services
University Hospitals Bristol NHS Foundation Trust
Aims of talk….
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Discuss the pitfalls of drug history taking
Introduce medicines reconciliation
Help you to reduce risk from prescribing
medicines
Identify sources of information which will
help you prescribe safely
Revision from 3rd year talk!
Give you pointers to ask on your
placements
Why me?
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You will do this every day
You will be responsible for your prescribing
You will make prescribing errors
You will be expected to prescribe to NPSA
competencies (Eg Anticoagulant & IVs)
You need to be aware of potential pitfalls
You need to think about prescribing safely
You need to know when to ask for help
What is a medication error ?
‘ a medication error is any
preventable event that
may cause or lead to
inappropriate medication
use or patient harm while
the medication is in the
control of health
professional, patient or
consumer’
Incidence of errors
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The precise incidence of medication errors
in the NHS is unknown
~10-20% of all ADRs are due to errors
In USA 1.8% of hospital admissions have
a harmful error leading to 7000 deaths per
year
In Australia – 1% of all admissions suffer
an ADR due to medication error
Common error types?
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Wrong patient
Contra-indicted
medicine
Wrong drug /
ingredient
Wrong dose /
freqency
Wrong formulation
Wrong route of
administration
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Poor handwriting on
Rx
Incorrect IV
administration
calculations or pump
rates
Poor record keeping
Paediatric doses
Poor administration
techniques
Most common types of
medication error reported
Commonest causes of
medication errors
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Lack of knowledge of the drug – 29%
Lack of knowledge about the patient – 18%
“rule” violations – 10%
“Slip” or memory loss – 9%
JAMA 1995;274:35-43
Top Therapeutic
Groups Reported
Prescribing responsibilities
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Drug
Dose
Route
Frequency
For parenteral therapy
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Diluent and infusion volume
Access line for adminsitration
Rate of administration
Duration of treatment
Allergies and sensitivities
• Provide a prescription that is
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LEGIBLE (!!!!!)
Legal
Signed
Giving ALL information
to allow safe
administration
Controlled
drugs
In your handwriting:
1. Name and address of patient
2. Drug and dose
3. Form and strength of the drug
4.
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Modified release
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Strength if liquids/injections
Total quantity (or no. of dosage
units) in WORDS and figures)
The requirements for a
hospital take-home
prescription are the same
Drug history taking
1.
2.
3.
4.
What information should be gathered
during a drug history?
What is the aim of the drug history?
Where do you find the information?
What is “Medicines Reconciliation”?
Drug Histories: What information?
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Current medication
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Dose
Form
Strength
Frequency
Indication
Past medication and treatment failures
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Over the counter medication
“Recreational” drugs
Adverse reactions
Allergies and sensitivities - with clinical
detail
Estimate of patient adherence /
concordance with their medicines
DHx: Information Sources
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GP admission letter
GP records – From surgery / fax
Patients own tablets
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“Dosetts” = Multi-compartment compliance aids
Written lists – Patient / carer
Nursing home form
Pharmacist patient records
Recent discharge letters
GP admission letter
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Do not always contain a drug history
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Can only contain those deemed relevant to
admission
Out-of-hours
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No information for out-of-hours GP services to
call on; so incomplete or reliant on patient’s
memory / own medication
GP records
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Should be definitive; but:
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May be inaccurate / incomplete if:
Recent discharge not reached GP and acted upon
 Recent discharge had changed medicines with no
explanation
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Some drugs are secondary-care only or issued
in specialist units eg post-transplantation /
specialist clinics (CF, psychiatric etc)
These may not be on the GP record
 The doses may be altered by the originating unit
not the GP, so GP records may not be accurate
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GP records - 2
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Private prescriptions may not be recorded
on GP computer
Watch the date last issued
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Has this been stopped?
Is the patient no longer taking the medicine
Adverse reaction?
 Lack of effect?
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Will have allergies and sensitvities
Patient’s own medicines
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Are these for the correct patient?
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Are they still taking these?
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Easy to pick up a relative’s medicines by mistake
Easy to miss if the same surname
Stopped without GP being aware
Stopped with GP agreement but still on GP list
Stopped a while ago but kept “just in case”
Contents of medicine cupboard emptied!
Compliance aid boxes have lists inside
Previous drug chart or discharge letter
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How current are these?
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More recent changes?
Check with the patient
Incidences of errors with typist-generated letters
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Co-careldopa 3.125mg tds – Prescribed on next
admission
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Was 31.25 tds
Electronic discharge summaries
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Errors from picking incorrect drop-down list
Nursing Home list
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MARs sheet
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Medication Administration Record
Similar to a hospital drug chart
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Should be an accurate list
Community pharmacist records
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If one pharmacy is used regularly this can
be a additional source of information
Open on saturdays
Will include all prescriptions dispensed fo
that patient including
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But may also miss hospital-only medicines
Top 10 drug groups most commonly associated
with preventable drug-related admissions
Drug group
All preventable drugrelated admissions
(%)
ADRs and over
treatment
(%)
Patient adherence
problems (%)
Antiplatelets
16.0
17.3
2.0
8.9
Diuretics
15.9
16.0
20.4
2.2
NSAIDs
11.0
12.0
4.1
0
Opioids
8.5
8.9
4.1
0
Beta-blockers
4.6
4.4
4.1
11.1
4.4
4.6
4.1
0
Drugs used in
diabetes
3.5
3.2
9.2
0
Positive inotropes
3.2
3.2
3.1
0
Corticosteroids
3.1
3.2
2.0
2.2
Antidepressants
3.0
3.2
2.0
2.2
Drugs affecting renin
–angiotensin system
Under
treatment
(%)
Howard et al Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin
Pharmacol 2006;63(2):136-147.
Other common pitfalls
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Prescribed & labelled ‘As directed’
Own tablets not brought in
Several possible strengths eg inhalers
Trade names – beware duplicates
Patient can’t remember
“Dosett” boxes X tablet identification
Asking about “your tablets” – Patients
will then miss off inhalers, creams etc!
Take extra care if:
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Impaired renal function
Hepatic dysfunction
Children
The elderly
Drug is unknown to you
Very new drug
Medicines Reconciliation: Definition
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Definition
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“Collecting an accurate list of the patient's
home medicines, using that list to write
prescriptions; and documenting changes or
discontinuation of medicines and doses”
• National Guidance
• National Institute for Health and Clinical
Excellence: Patient Safety Guidance 1.
Technical patient safety solutions for
medicines reconciliation on admission of
adults to hospital.
<http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11897>
Medicines Reconciliation: Process
1.
Verification:
Collection of the medication history
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Obtaining a complete and accurate list of each patient's current
medications (medication history) including name, dosage, frequency
and route
Clarification:
Ensuring that the medications and doses are appropriate
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3.
Comparing the in-patient prescription or TTA to the medication history
Reconciliation:
Documentation of changes in the prescriptions
Resolving any discrepancies that may exist between the medication
history list and prescribed medicines before an adverse drug event
(ADE) can occur
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Note: ADEs can result from omitted drugs or doses
This is done at admission, on transfer between levels of care, on discharge
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If we don’t reconcile medication?
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Systematic review showed 30-70% for unintentional
variances between the medication patients are taking
and their subsequent in-patient prescriptions1
Examples
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Omeprazole started in ITU for prevention of stress ulceration. No
GI Hx.
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Carried on for 3 years
Admitted for surgery. PMH: RA, HTN
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GP history not used
Not given regular meds for 6 days
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Prednisolone 5mg, Methotrerxate, Alendronic acid, ramipril,
Bendroflumethiazide, Alendronic acid, Folic Acid
Painful joints, stiffness, BP
1: Campbell etal. A systematic review of the effectiveness of interventions aimed at preventing medication
error (medicines reconciliation) at hospital admission. University of Sheffield School of Health and Related
Research. September 2007
If we don’t give the GP full details?
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How will she know what we have done?
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Their records will not be up-to-date
Patients are confused
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What we have stopped and why
What we have started and why
What they should look out for or monitor, Tx goals
Different lists from hospital and the GP
Medication is stopped by GP as no idea why
started
There will be errors on the next admission
Minimum information to be supplied at
discharge
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Complete and accurate patient details (full name, date of birth,
weight if under 16 years, NHS number, consultant, ward discharged
from, date of admission, date of discharge)
The diagnosis of the presenting condition plus co-morbidities
Procedures carried out
A list of all the medicines prescribed for the patient on discharge
(and not just those dispensed at the time of discharge which are in
addition to the regular medication)
Dose, frequency, formulation and route of all the medicines listed
Medicines stopped and started, with reasons
Lengths of courses where appropriate (e.g. antibiotics, clopidogrel)
Details of variable dosage regimens (e.g. oral corticosteroids,
warfarin etc)
Known allergies, hypersensitivities and previous drug interactions
Any additional patient information provided such as corticosteroid
record cards, anticoagulant books etc.
Further inflromation available at url:
<http://npci.org.uk/medicines_management/safety/reconcil/process_tools/pt_data_r
econciliation.php>
Safer Prescribing
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Know your patients
Know your medicines
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Use a limited number if possible to aid familarisation –
Prescribing Formularies
Use your resources
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Peers
Pharmacists
Specialists (medical & non-medical)
Guidelines and decision support help
National help
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National Patient safety Agency – Alerts and reports
MHRA – Monthly newsletter for prescribing and adverse reactions
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Sign-up for this on website
Alert 20:Promoting Safer Practice
With Injectable Medicines
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NPSA receives 800
incident reports a
month concerning
injectable medicines.
24% of all
medication incident
reports.
58% of incident
reports leading to
death and severe
harm.
Decision-making with pharmacological
therapy: ENCoRE
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Explore
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identify patient
nature of symptoms
other medicines or
treatment
allergies and ADRs
adherence to
treatment
exclude serious
disease
No medication option
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unnecessary
contra-indicated
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Care over
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Refer
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older people
children
pregnancy/lactation
potentially serious
problems
persistent symptoms
Explain
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suggested course of
action
Pharmacy help
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View charts daily
Check doses, calculations etc
Check interactions
Check appropriateness
Provide advice and information
Help with prudent antibiotic use
Medication reviews for patients
On admissions units
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Take medication histories
Help with reconciliation
Medicines Information Dept.
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All hospitals have access to
one - phone/bleep
Any medicines-related
enquiry eg
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Treatment options
Drugs in pregnancy
Evidence collection and
collation
There to help you prescribe
safely
Prescribing guidelines and
resources
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Developed to standardise treatment
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Evidence based use of medicines
Find out what is available in your Trust
Usually intranet-based
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Especially: If evidence is conflicting / high risk /
high cost
BNF / Medusa intravenous drugs guide
Policies
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Medicines codes or policies
MUST read and follow
Intranet-based BNF – Localised with Formulary/Local text
Intranet IV administration Guide “Medusa”
Management of Acute Hyperkalaemia in Adults
clinical features of acute hyperkalaemia
hyperkalaemia is defined as a serum potassium greater than 5.2 mmol/L
other signs and symptoms (1)
usually asymptomatic but can include;
•
tingling
•
•
paraesthesia
•
muscle weakness
flaccid paralysis
ECG signs
if present treat urgently
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tall, peaked T-waves, followed by flattening of P-wave, prolongation of PR interval, QRS
widening, and development of S-wave,
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arrhythmias (bradycardia, VT, VF)
•
deterioration to asystole at a serum potassium around 7mmol/L or more
i
i
potential precipitant
causes
8 GuidePoint
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Page 46 of 11
Prescribing Quiz
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Teams of 4/5 people
If need additional
information write
‘need info on . . .’
Question 1
A frail 80 year old lady is admitted with falls, a chest infection and
feeling sick.
PMH
DHx
AF and Hypertension
Bendroflumethazide 5mg daily
Atenolol 50mg daily
Ramipril 1.25mg daily
Aspirin 75mg daily
Warfarin 3mg daily
Digoxin 250 micrograms daily
O/A
Benzylpenicillin IV 2.4g qds and
Ciprofloxacin po 400mg bd
List 5 potential problems or issues with this prescription….
Question 2
Drug chart =
Benzylpenicillin 2.4G IV qds
Ciprofloxacin 750mg bd
After 2 days therapy the patient can be
discharged – write the take home prescription
(TTO – To Take Home)
(TTA – To Take Away)
Question 3
A patient is admitted on-call via GP cover
service. The admissions letter states the
medicines as:
ISMN 60mg / day
Nifedipine 30mg /day
Atorvastatin 30mg / day
Fill in the ‘in-patient’ drug chart for this patient
Question 4
2001 NHS goal – By how much did the
number of serious errors in the use of
prescribed medicines need to reduced
by 2005?
Question 5
Give the generic names of the following
 Zocor
 Tegretol
 Istin
 Losec
Question 6
A patient is going home and needs the
following:
MST 40mg bd for 14 days
Please write the prescription (excluding
name and address)
Question 7
A patient needs Vancomycin 500mg bd IV
Write up in patient drug chart
Question 8
Patient is due to go home and has the
following on in patient Rx:
Amiodarone 200mg tds (started 4 days ago)
Simvastatin 10mg on
Furosemide 40mg bd (for post-op peripheral
oedema)
Zopiclone 7.5mg on (started in hospital)
Write patients TTO for 1 mth
Answer: Question 1
Bendroflumethazide 5mg daily
Dose for HTN is 2.5mg
Atenolol 50mg daily
? cause of falls
Ramipril 1.25mg daily
Seems low, has this been dose-titrated?
Aspirin 75mg daily
Aspirin and warfarin interaction
Warfarin 3mg daily
Warfarin and antibiotic interactions
Digoxin 250 micrograms daily
Dose ? high as elderly – check levels
Benzylpenicillin IV 2.4G qds
Ciprofloxacin po 400mg bd
= IV dose, oral dose is 750mg bd
1 mark per green answer
Answer: Question 2
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Change IV to oral
Amoxycillin 500mg tds for 5 days
Ciprofloxacin 750mg bd for 5 days
-1 if unsigned
1 marks each
Answer: Question 3
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Isosorbide mononitrate MR 60mg
prescribed at 8am
Nifedipine 30mg MR prescribed daily
Atorvastatin 30mg prescribed at night
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But an unlikely dose as generally 10mg,
20mg or 40mg (No 30mg tablet) - Check
1 mark each
-1 if no signature included
-1 mark if no routes included
Answer: Question 4
40%
Answer: Question 5
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Zocor
Tegretol
Istin
Losec
simvastatin
carbamazepine
amlodipine
omeprazole
Answer: Question 6
Morphine (Sulphate) MR (SR) 40mg
BD (for 14 days)
28 (twenty eight) 30mg MR tablets
28 (twenty eight) 10mg MR tablets
(1120mg – one thousand, one hundred and
twenty milligrams)
Sign, date and print name
Answer: Question 7
Drug
8
x
Vancomycin
Dose
500mg
Signature
Route
IV
Start Date
Stop Date
6.1.9
Review
10.1.9
Pharm
12
18
Squiggle
Additional instructions
In 100mls Sodium chloride 0.9% over 60
minutes via peripheral line
24
x
Answer: Question 8
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Amiodarone 200mg tds for 4 days then
bd for 7 days then daily
Simvastatin 10mg on
Frusemide 40mg bd for a set time
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Add a note to the GP for review
will accept a dose change eg 40mg om
No zopiclone should be required as
started in hospital
Summary: Safe prescribing
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Clear and unambiguous
Use approved names
No abbreviations eg ISMN
Unless G or mg then write units in full
(micrograms or nanograms)
Avoid decimal points – if needed then make very
clear: .5ml X 0.5ml 
Avoid a trailing zero: 1.0mg X 1mg 
Avoid fractions: 0.5mg X 500 micrograms 
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Rewrite charts regularly
If amend prescription re-write or sign and date
amendment
For frequency use standard abbreviations eg od
/ bd / tds etc
If using a dose by weight calculate the dose
needed (NOT 1.5mg/kg)
Take time (e.g. to read patient information)
Use your resources
When in doubt - ASK