Prescribing Safely

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Prescribing Safely
Narinder Bhalla Lead Pharmacist Clinical
Governance Addenbrookes NHS Trust March 2005
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Objectives

• What is a medication error?
• What is a prescribing error?
• Why do errors occur?
• Different drug charts
• Examples of common errors
• High risk drugs
• Good prescribing principles

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What is the size of the problem?

• Every year in the NHS
• 400 die/seriously injured by medical devices.
• 10,000 have serious adverse reaction to a drug
• Adverse events that lead to harm occur in 10 of
  hospital admissions.
• 28,000 written complaints about clinical
  treatment in hospital.
• 400m to settle clinical negligence claims.
• (potential liability of 2.4 billion)
• (ref An Organisation with Memory)

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When it goes wrong
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Deadly Toll of Medication Errors

• Pilot study in 2 London hospitals
• What is clear is that we need to know more about
  errors and do more about them
  - Sir George, BMJ March 2002

Adverse events in gt1 in 10 pts
1/3 of these are serious
In 8 of these cases, it lead to the patients
death
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To Err Is Human
The Audit Commission A spoonful of sugar -
medicine management in NHS hospitals

• Core curricula at medical schools do not provide
  a thorough knowledge of safe medicine prescribing
  and administration.
• DoH goal for NHS to reduce medication errors by
  40

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Definition of Medication Incident/Error

• A medication error is A preventable prescribing,
  dispensing, drug
• Administration or clinical advice (relating to
  drugs) error.

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Causes of medication incidents

• Fatigue Sleep deprivation
• Hunger Long lapses between food/drink
• Concentration Lapses
• Stress Loss of control/cutting corners
• Distraction
• Lack of training
• Lack of access to information (not timely)
• Other factors Alcohol, drugs illness

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Common Prescribing Errors

• Wrong drug (e.g. drugs that sound alike)
• Wrong dose
• Inappropriate Units
• Poor/illegible prescriptions
• Failure to take account of drug interactions
• Omission
• Wrong route/multiple routes (IV/SC?PO)
• Calculation errors (important in Paediatrics)
• Poor cross referencing
• Infusions with not enough details of diluent,
  rate etc. Poor cross-referencing between charts
• Once weekly drugs
• Multiple dose changes

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Spot the difference?
Look alike drugs contribute to medication errors
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Spot the difference?
Look alike drugs contribute to medication errors
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Spot the difference?
Look alike drugs contribute to medication errors
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Lidocaine

• Administering the wrong drug could be fatal
• NHS standard
• Water
• Sodium chloride
• Lidocaine (lignocaine)

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Examples

• Drugs that sound alike
• Clotrimazole/Co-trimoxazole
• Carbamazapine/carbimazole
• Risedronate/Methotrexate
• Drugs that look similar in writing
• ISMN / ISTIN

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Once weekly drugs

• Oral methotrexate
• Methotrexate prescribed
• as 10mg once daily,
• when correct dose
• frequency is once
• weekly.

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Opioids

• Not always bioequivalent by different routes
• e.g. IM Morphine 10mg 2.5-5mg IV
• Codeine
• Not given IV, the only licensed parentral route
  is IM
• Dihydrocodeine
• Not given IV, appropriate parentral routes are SC
  or IM.
• If codeine or dihydrocodeine given IV, 100
  bioavailability therefore
• danger of respiratory depression and other opioid
  side-effects.
• Slow- release/Non- slow release formulations
• MST/Sevredol
• Oxycontin/Oxynorm

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Cytotoxic Drugs

• The same levels of care must apply whether a
  cytotoxic drug is being used to treat cancer or
  another indication e.g. rheumatology,
  dermatology.
• The same levels of care must apply whether a
  cytotoxic drug is being used parenterally or
  orally.
• Initiation of cytotoxic chemotherapy should be by
  a Consultant. Subsequent prescribing should be a
  Consultant or SpR.
• Intravenous cytotoxics are prepared within a
  chemotherapy unit in Pharmacy.
• Intravenous cytotoxics are only administered in
  specified areas in the hospital.
• Any staff of any grade may not participate in ANY
  WAY in intrathecal administration of cytotoxics
  unless specifically accredited to do so. The
  only exception is observation with NO
  participation.

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Examples

• Inappropriate units
• Insulin Mixtard 30
• Dose 10 i.u. could be read as 101 units
• Drug Interactions
• Digoxinamiodarone
• Warfarinamiodarone

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Prevention of Medication Errors

• The Five Rs
• Right Patient
• Right Drug
• Right Dose
• Right Route
• Right Time

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Principles of Good Prescribing

• Use addressograph for patient details
• Complete allergy box and alert label
• Use generic drug names
• State drug, dose, strength, route and frequency
• Avoid abbreviations
• Avoid multiple route prescribing (i.e. im/sc/po)
• State dose as grams, mg, mcg.
• Make administration of once weekly drugs clear
• To amend a prescribed drug draw a line through
  it, date and initial, then rewrite as new
  prescription.

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Sources of Prescribing Info

• Trust Prescribing Policy
• BNF/eBNF
• IV guides/monographs
• Trust Formulary
• Specialist references (e.g. Paediatric)
• Summary of Product Characteristics
• Pharmacist
• Medicines Information
• Electronic access to central library of Trust
  approved guidelines.

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BNF What can it do for me?

• Front section
• Prescribing guidance, prescription writing CD
  prescribing
• Prescribing in children, elderly palliative
  care
• Emergency treatment of poisoning
• Middle section
• Approved Drug Name with indications, S/E,
  cautions dose
• Back section
• Appendixes interaction, pregnancy
• Approved abbreviations (BNF Back page)

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Formularies Essential Drugs

• National formularies (e.g. the BNF) provide an
  independent source of advice
• Hospital formularies reflect hospital choices
• WHO provide a model list of essential drugs
  (300 items) some controversial!

Most prescribing limited to 100 formulations
(vs. gt 60,000 total)
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Controlled Drugs Prescriptions

• Handwritten
• NAME, FORM STRENGTH of drug and dose
  Morphine sulphate SR tablets 10mg 20mgbd
• Methadone liquid 1mg/ml
  10ml od
• TOTAL QUANTITY in WORDS and FIGURES
• 50 (Fifty) tablets
• 20 (twenty) ml
• YOUR Signature and DATE (include bleep no.)

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Hospital Prescribing

• Includes
• Evaluation of patients current medication
• Selecting medication for treatment - indication,
  formulary, licence agreements, efficacy
• Stating considerations - antibiotics duration
  of treatment
• - warfarin discharge dose next INR date
• Discharge medication (or TTO) not just a
  rehash of the drug chart

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Before Writing a Drug Chart

• ALLERGIES
• COMPLETE Drug History
• what they are taking today and why
• what has been stopped recently
• what they are buying themselves
• OTC, herbal, homeopathic and frequency
• what are they unable to take and why
• HRT oral contraceptives

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Before Writing a Drug Chart

• Sources of information on current drugs
• Patient
• GP letter stating current medication
• Repeat prescribing slip
• Medical notes
• Community Pharmacist
• Patients own drugs
• What have they got with them?
• Can you positively identify each drug?
• Is the dosage correct?
• What state are they in can it be used?
• Can their relatives/carer bring it in?

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Prescription/Drug Charts

• ALLERGIES
• BLOCK CAPITALSApproved name in BNFNOT trade
  name abbreviations
• Dose, frequency and time, route
• Sign entry with bleep number

If in doubt check, never guess see BNF
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Prescription/Drug Charts
Tramadol 50mg 7/11 S Jones
PO qds prn. Max 200mg/24hrs

• PRN criteria
• frequency
• max dose
• indication

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Specify dose

• Gliclazide 80mg
• Diclofenac50mg, 75mg or 100mg?
• Cipramil10mg or 20mg?

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Completing Drug Charts Important points

• Cross reference drugs prescribed on other charts
  back to the main drug chart.
• Care when rewriting drug charts / transferring
  information to discharge summaries.
• Always double check your prescription - you are
  legally responsible for it.

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Parenteral Administration Chart
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Parenteral Administration In some hospitals it is
part of the usual drug chart
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Discharge Prescriptions

• Record all drugs the patient should take even if
  no supplies are required on discharge.
• Record drugs that have been stopped or
  significant changes.

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Warfarin Chart
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Subcutaneous Insulin
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Insulin Chart
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IV Medication

• Check drug indications dosages as in BNF
• BNF Appendix 6 guidelines additives
• IV Monograph
• Boluses and short infusions on main drug chart
• Continuous IV infusions on fluid chart and cross
  referenced back to main drug.
• KCL strong solution now handled as CD

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