Prescribing Safely

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Prescribing Safely

• Kevin Gibbs
• Pharmacy Manager Clinical Services
• University Hospitals Bristol NHS Foundation Trust

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Aims of talk.

• 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

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Why me?

• 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

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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

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Incidence of errors

• 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

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Common error types?

• Wrong patient
• Contra-indicted medicine
• Wrong drug / ingredient
• Wrong dose / freqency
• Wrong formulation
• Wrong route of administration

• Poor handwriting on Rx
• Incorrect IV administration calculations or pump
  rates
• Poor record keeping
• Paediatric doses
• Poor administration techniques

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Most common types of medication error reported
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Commonest causes of medication errors

• Lack of knowledge of the drug 29
• Lack of knowledge about the patient 18
• rule violations 10
• Slip or memory loss 9
• JAMA 199527435-43

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Top TherapeuticGroups Reported
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Prescribing responsibilities

• Drug
• Dose
• Route
• Frequency
• For parenteral therapy
• Diluent and infusion volume
• Access line for adminsitration
• Rate of administration
• Duration of treatment
• Allergies and sensitivities

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Provide a prescription that is

• LEGIBLE (!!!!!)
• Legal
• Signed
• Giving ALL information to allow safe
  administration

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Controlled drugs

• In your handwriting
• Name and address of patient
• Drug and dose
• Form and strength of the drug
• Modified release
• 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
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Drug history taking

1. What information should be gathered during a drug
   history?
2. What is the aim of the drug history?
3. Where do you find the information?
4. What is Medicines Reconciliation?

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Drug Histories What information?

• Current medication
• 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

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DHx Information Sources

• GP admission letter
• GP records From surgery / fax
• Patients own tablets
• Dosetts Multi-compartment compliance aids
• Written lists Patient / carer
• Nursing home form
• Pharmacist patient records
• Recent discharge letters

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GP admission letter

• Do not always contain a drug history
• Can only contain those deemed relevant to
  admission
• Out-of-hours
• No information for out-of-hours GP services to
  call on so incomplete or reliant on patients
  memory / own medication

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GP records

• Should be definitive but
• May be inaccurate / incomplete if
• Recent discharge not reached GP and acted upon
• Recent discharge had changed medicines with no
  explanation
• 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

• Private prescriptions may not be recorded on GP
  computer
• Watch the date last issued
• Has this been stopped?
• Is the patient no longer taking the medicine
• Adverse reaction?
• Lack of effect?
• Will have allergies and sensitvities

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Patients own medicines

• Are these for the correct patient?
• Easy to pick up a relatives medicines by mistake
• Easy to miss if the same surname
• Are they still taking these?
• 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

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Previous drug chart or discharge letter

• How current are these?
• More recent changes?
• Check with the patient
• Incidences of errors with typist-generated
  letters
• Co-careldopa 3.125mg tds Prescribed on next
  admission
• Was 31.25 tds
• Electronic discharge summaries
• Errors from picking incorrect drop-down list

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Nursing Home list

• MARs sheet
• Medication Administration Record
• Similar to a hospital drug chart
• Should be an accurate list

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Community pharmacist records

• 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
• But may also miss hospital-only medicines

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Top 10 drug groups most commonly associated with
preventable drug-related admissions
Drug group All preventable drug-related admissions () ADRs and over treatment () Patient adherence problems () Under treatment ()
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
Drugs affecting renin angiotensin system 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
Howard et al Which drugs cause preventable
admissions to hospital? A systematic review. Br J
Clin Pharmacol 200663(2)136-147.
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Other common pitfalls

• Prescribed labelled As directed
• Own tablets not brought in
• Several possible strengths eg inhalers
• Trade names beware duplicates
• Patient cant remember
• Dosett boxes X tablet identification
• Asking about your tablets Patients will then
  miss off inhalers, creams etc!

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Take extra care if

• Impaired renal function
• Hepatic dysfunction
• Children
• The elderly
• Drug is unknown to you
• Very new drug

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Medicines Reconciliation Definition

• Definition
• 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.

lthttp//www.nice.org.uk/guidance/index.jsp?action
byIDo11897gt
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Medicines Reconciliation Process

• Verification
• Collection of the medication history
• 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
• 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
• 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 dont reconcile medication?

• Systematic review showed 30-70 for unintentional
  variances between the medication patients are
  taking and their subsequent in-patient
  prescriptions1
• Examples
• Omeprazole started in ITU for prevention of
  stress ulceration. No GI Hx.
• Carried on for 3 years
• Admitted for surgery. PMH RA, HTN
• GP history not used
• Not given regular meds for 6 days
• 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
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If we dont give the GP full details?

• How will she know what we have done?
• What we have stopped and why
• What we have started and why
• What they should look out for or monitor, Tx
  goals
• Their records will not be up-to-date
• Patients are confused
• 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

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Minimum information to be supplied at discharge

• 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
• lthttp//npci.org.uk/medicines_management/safety/re
  concil/process_tools/pt_data_reconciliation.phpgt

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Safer Prescribing

• Know your patients
• Know your medicines
• Use a limited number if possible to aid
  familarisation Prescribing Formularies
• Use your resources
• Peers
• Pharmacists
• Specialists (medical non-medical)
• Guidelines and decision support help
• National help
• National Patient safety Agency Alerts and
  reports
• MHRA Monthly newsletter for prescribing and
  adverse reactions
• Sign-up for this on website

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Alert 20Promoting Safer Practice With Injectable
Medicines

• 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.

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Decision-making with pharmacological therapy
ENCoRE

• Explore
• identify patient
• nature of symptoms
• other medicines or treatment
• allergies and ADRs
• adherence to treatment
• exclude serious disease
• No medication option
• unnecessary
• contra-indicated

• Care over
• older people
• children
• pregnancy/lactation
• Refer
• potentially serious problems
• persistent symptoms
• Explain
• suggested course of action

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Pharmacy help

• 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
• Take medication histories
• Help with reconciliation

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Medicines Information Dept.

• All hospitals have access to one - phone/bleep
• Any medicines-related enquiry eg
• Treatment options
• Drugs in pregnancy
• Evidence collection and collation
• There to help you prescribe safely

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Prescribing guidelines and resources

• Developed to standardise treatment
• Especially If evidence is conflicting / high
  risk / high cost
• Evidence based use of medicines
• Find out what is available in your Trust
• Usually intranet-based
• BNF / Medusa intravenous drugs guide
• Policies
• Medicines codes or policies
• MUST read and follow

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Intranet-based BNF Localised with
Formulary/Local text
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Intranet IV administration Guide Medusa
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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

• flaccid paralysis

• paraesthesia

• muscle weakness

• ECG signs
• if present treat urgently
• tall, peaked T-waves, followed by flattening of
  P-wave, prolongation of PR interval, QRS
  widening, and development of S-wave,
• arrhythmias (bradycardia, VT, VF)
• deterioration to asystole at a serum potassium
  around 7mmol/L or more

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Prescribing Quiz

• Teams of 4/5 people
• If need additional information write need info
  on . . .

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Question 1

• A frail 80 year old lady is admitted with falls,
  a chest infection and feeling sick.
• PMH AF and Hypertension
• DHx 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.

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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)
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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
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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?
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Question 5

• Give the generic names of the following
• Zocor
• Tegretol
• Istin
• Losec

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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)
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Question 7
A patient needs Vancomycin 500mg bd IV Write up
in patient drug chart
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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
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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 Digoxi
n 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
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Answer Question 2

• Change IV to oral
• Amoxycillin 500mg tds for 5 days
• Ciprofloxacin 750mg bd for 5 days
• -1 if unsigned
• 1 marks each

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Answer Question 3

• Isosorbide mononitrate MR 60mg prescribed at 8am
• Nifedipine 30mg MR prescribed daily
• Atorvastatin 30mg prescribed at night
• 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

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Answer Question 4
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Answer Question 5

• Zocor simvastatin
• Tegretol carbamazepine
• Istin amlodipine
• Losec omeprazole

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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
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Answer Question 7
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Answer Question 8

• Amiodarone 200mg tds for 4 days then bd for 7
  days then daily
• Simvastatin 10mg on
• Frusemide 40mg bd for a set time
• 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

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Summary Safe prescribing

• 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