1. 10 top tips for safer prescribing and review of medicines
RCN Advanced Nurse Practitioner
Forum conference 2011
10 top tips for safer prescribing and review of medicines
Dr Duncan Petty
Lecturer Practitioner
School of Health Care, University of Leeds

2. 10 top tips for safer prescribing and review of medicines
Dr Duncan Petty
Lecturer practitioner, University of Leeds
Director , Prescribing Support Services Ltd

3. Scale of the problem
5% of hospital unplanned admissions are due to medicines
7 out of 10 care home residents will experience a medicine error each year
Around 7.5% of prescriptions in general practice contain an error

4. Where do things go wrong?
Poor prescribing decision
Wrong drug, dose, route, frequency and quantity
Poor patient communication leading to patients not taking medicines as intended
Lack of monitoring and follow up
Interface communication (especially primary and secondary care and visa versa).
Professor Tony Avery

6. Who is most at risk? Very young and the very old
Those with multiple serious morbidities
Those on a range of hazardous medications
Those with serious acute medical problems
Those who are ambivalent about medication-taking or who have difficulty understanding or remembering to take medication
Professor Tony Avery

7. A 85 year old lady is prescribed diclofenac 50mg three times a day for osteoarthritis. She takes it regularly. She also has cardiovascular disease. She is admitted with a GI bleed.

8. Aim
To describe in detail 10 behaviours that will improve the quality of your prescribing decisions and therefore should improve patient outcomes whilst minimising harm

9. By the end of this session you will be able to:
describe how prescribing and poor review can lead to patient harm.
describe ways in which you can improve your prescribing
identify the important elements of medicine history taking and medication review

10. 10 ideas for safer prescribing
Be familiar with your area of prescribing
Don't prescribe other peoples recommendations unless you are competent and confident
Follow the evidence base
Know what your patient is taking
Involve the patient
Keep the treatment as simple as possible
Stop things that don't work or are no longer needed
Review and monitor
Beware drug-drug and drug condition interactions
Apply the Goldie locks rule to doses

11. Be familiar with your area of prescribing
Obviously ! But how
Use only a few medicines
Learn to use them well
Keep up to date
Only introduce new medicine when evidence is compelling.

12. Warfarin or dabigatrin for stroke reduction in atrial fibrilliation?

13. 2. Don't prescribe other peoples recommendations unless you are competent and confident.
Obviously again. But need to consider
When will you continue a medicine initiated by another prescriber ?
What information do you need to continue the prescribing ?
What ongoing arrangements do you need in place to continue the prescribing?

14. Discharge letter from cardiologists says to change atenolol to bisoprolol. The letter states he is also on verapamil. Would you be happy to continue this prescription?

15. Asthma death girl 'was let down'
BBC News 24th May 2005
A sheriff has hit out at the "complacency"
of health professionals and a drugs
manufacturer over the safety of an asthma
inhaler steroid .A fatal accident inquiry found
that the death in 2001 of Emma Frame, from
Strathaven, Lanarkshire, might have been
avoided if precautions were taken.
Emma, five, had been given five times the licensed dose of fluticasone.

16. Inhaled steroids in children

17. 3. Follow the evidence base New drugs
Use trustworthy and unbiased sources or information
Follow local and national protocols and guidance
Be certain drug improves Patient Orientated Outcomes rather than surrogate markers.

18. Atypical antipsychotics may worsen cognition in Alzheimer’s
Patient Orientated Evidence That Matters (POEMs)
They address a question that practitioners encounter
They measure outcomes that practitioners and their patients care about: symptoms, morbidity, quality of life, and mortality
They have the potential to change the way practitioner practise
Atypical antipsychotics may worsen cognition in Alzheimer’s

19. Shifting through the evidence Journal of Family Practice 1994;38:505-513
Frequency common
Frequency rare
Patient orientated evidence
Best
Best source of evidence
Relevance 1
Only if time
May not be relevant
Relevance 2
Disease orientated evidence
Danger
Misleading
Relevance 3
Worst
Read only if very interested
Relevance 4

20. Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: meta-analysis of randomised controlled trials. BMJ 2011; 343 doi: /bmj.d4169
“This meta-analysis of data from 13 randomised controlled trials showed no benefit of intensive glucose lowering treatment on all cause mortality or death from cardiovascular causes in adults with type 2 diabetes. “
“Overall, the absolute benefit of treatment for five years was modest; 117 to 150 people would need to be treated to avoid one myocardial infarction, 32 to 142 to avoid one episode of microalbuminuria,”
“The absence of benefits from intensive glucose lowering treatment further illustrates why relying on surrogate end points for treating people is a fallacy.”

21. This meta-analysis
HBA1c at baseline range (7.5 to 9.5%)
At study end (7.0 to 6.4%)
QOF The percentage of patients with diabetes in whom the last IFCC-HbA1c is 59 mmol/mol (equivalent to HbA1c of 7.5% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months

23. Surrogate markers
HbA1c
Blood pressure
Cholesterol
Bone density

24. 4. Know what your patient is taking
Medicines history taking
Medicines reconciliation

25. A patient with Ulcerative Colitis comes to see you
A patient with Ulcerative Colitis comes to see you. She says she takes azathioprine and mesalazine. When you look back through the specialists letters there is no mention if mesalazine yet the practice has prescribed it for the last 5 years.

26. Medicines reconciliation
“a technical process to ensure that the prescribed and non-prescribed medicines (drug, dose/strength, form, route, frequency) that a patient reports to be taking before a transition in care across a health care or social care boundary corresponds with those prescribed afterwards by identifying and resolving discrepancies and communicating these to the patient and the patient’s health care providers.”

27. The NPC 3C’s of medicines reconciliation
Collect an accurate medication history using the most recent sources of information to create a full list of current medicines- record the information sources
Check this list of medicines against the current prescription and ensure that the medicines, formulation, route and doses are appropriate
Communicate any changes, omissions and discrepancies and remember to document and date any changes

28. Problems associated with transfer of care
The Institute for Healthcare Improvement showed that poor communication of information at transition points was responsible for up to 50% of all medication errors
AND
Up to 20% of adverse drug events in hospitals
(IHI 2004 ,

29. Problems associated with transfer of care
Two literature reviews reported unintentional variances of 30-70% between the medications patients were taking before admission and their prescriptions on admission
Cornish PL et al. Archives of Internal Medicine 2005;
Gleason KM et al. Amer. J. of Health-System Pharmacy 2004;
Reference the literature reviews
Cornish, P. L., Knowles, S. R., Marchesano, R., Tam, V., Shadowitz, S., Juurlink, D. N.,
and Etchells, E. E. Unintended Medication Discrepancies at the Time of Hospital
Admission. Archives of Internal Medicine 2005;
Gleason, K. M., Groszek, J. M., Sullivan, C., Rooney, D., Barnard, C., and Noskin, G. A.
Reconciliation of discrepancies in medication histories and admission orders of newly
hospitalized patients. American Journal of Health-System Pharmacy 2004;
1695.

30. Where do errors occur?
Errors occur at the following stages during the admission process:
Determining what patients are currently taking
Transcribing details into the hospital records
Prescribing medication for the patient after admission

31. How accurate are the information sources?
Studies in elderly patients showed that what the patients were taking and what the GP thought they were taking differed in 50-74% of patients studied .
Lowe CJ et al. Br.J.Clin Pharmacol 2000;50:172-5 and Bikowski R et al. JAGS 2001:49 (10)
70% of drug-related problems were only recognised through a patient interview.
Jameson JP & Van Noord GR. Ann Pharmacother. 2001;35:

32. Reconciliation is not enough

33. Involve the patient 5. Involve the patient or carer

34. Mr B is an 87 year old gentleman who has lived in a care home
Mr B is an 87 year old gentleman who has lived in a care home. He suffers from dementia. Following a mechanical fall he is prescribe Ibandronic acid 150 mg once monthly by the GP.

35. After two grand mal seizures he was started on levetiracetam
After two grand mal seizures he was started on levetiracetam. As levetiracetam is known to cause drowsiness and thrombocytopenia, careful titration of the dose and monitoring of FBC was advised.
Five days after discharge he developed sore gums. He was seen by a nurse practitioner, who recommended Bonjela. The cause of the sore gums was thought to be Fixodent®, a denture adhesive product used to keep dentures in place. He previously used a different adhesive product without any problems.

36.  One day later, the whole mouth was very sore and the patient experienced difficulties swallowing. The inflammation appeared to have spread over the mucosa of the inner cheeks, the upper palate and the pharynx. The prescription was changed to Nystatin based on the diagnosis of oral thrush. A current course of antibiotics was considered as the cause.
Another day later, the condition deteriorated, blisters had spread over the whole mucosa of the mouth, including the upper palate and the pharynx. He also started to develop blisters on the lips.

37. Does not respect patient’s autonomy Widely used term in literature
Compliance
“The extent to which the patient’s behaviour matches the prescriber’s recommendations”
Does not respect patient’s autonomy
Widely used term in literature
HORNE, R., J. WEINMAN, N. BARBER, R. ELLIOTT, and M. MORGAN, Concordance, adherence and compliance in medicine taking.

38. Adherence
“The extent to which the patient’s behaviour matches agreed recommendations from the prescriber”
Informed adherence
BOND, C., (ed.), Concordance. Pharmaceutical Press: London. Selected chapters.

39. Task 1: Rates of non-Compliance
Condition
Rate of non-compliance (%)
Contraception 8
Asthma 20
Epilepsy
30-40
Hypertension 40
Diabetes
40-50
Arthritis
55-71
8; 20; 30-50; 40; 40-50; 55-71

40. What level of adherence?2
Disease
Desired outcome
Adherence rate needed
Hypertension
Normotension
80%
(50% not sufficient) MI
Survival at 1 year
>75% 3x as likely
HIV
Efficacy/resistance
>95%

41. Is there a typical non-adherent patient?
Patient related risk factors
Mental illness
Physical disability
Cultural/language
Reading ability
Home circumstances
Perceptions/health beliefs
Education?
Social class?
Age?

42. Unintentional vs. intentional Non-adherence
Conscious decision not to take medication as prescribed
Unintentional
Patient wants to take medicine but is unable to do so

43. Concordance – a solution?
“An agreement reached after a negotiation between a patient and a healthcare professional that respects the beliefs and wishes of the patient in determining whether, and how, medicines are taken”
Patients view takes precedence if can’t reach agreement.

44. Is there a typical non-adherent patient?
Medicine related factors
Number of daily doses
Number of medicines
Non-oral dose forms
Complex devices
Tablet size
Side effects

45. A high % of patients change their own treatment
Current asthma treatment
Total (n=517)
Reliever once a day, no other medication (n=169)
Reliever once/twice a day, no other medication (n=85)
Reliever and preventer, once/twice a day, no other medication (n=196)
Reliever and preventer, once/twice a day, plus other medication (n=67)
When a patient’s asthma does vary, a large % of patients change their own asthma treatment in response to this change.
References:
The Living and Breathing Survey. Haughney J, Barnes G,
Partridge MR, Cleland J. Primary Care Respiratory Journal March 2004
10%
20%
30%
40%
50%
60%
70%
80%
A high % of patients change their own treatment
due to this asthma variability
Haughney J, Barnes G, Partridge M, et al. Prim Care Resp J 2004; 13: 26-35

46. A high % of patients who thought their asthma was under control were experiencing regular symptoms
100%
80%
60%
40%
20%
It is commonly thought by both patients and clinicians that asthma is under control. However, when questioned, patients were experiencing symptoms despite being under the impression that their asthma was actually under control.
References:
The Living and Breathing Survey. Haughney J, Barnes G,
Partridge MR, Cleland J. Primary Care Respiratory Journal March 2004
Total (n=517)
Every day – both day and night (n=120)
Every day – either during the day or during the night (n=92)
2-3 times a week (n=127)
Once a week (n=86)
Once a month (n=50)
Less than once a month (n=42)
Percentage of respondents who thought that their asthma was under control, related to the frequency of asthma symptoms
Haughney J, Barnes G, Partridge M, et al. Prim Care Resp J 2004; 13: 26-35

47. Profile of 425 severe exacerbations
% change
100
Rescue b2 80
Morning PEF
Nighttime symptoms (most specific indicator) 60 40
The FACET study gives us a chance to examine events leading up to exacerbation in a large cohort.
A 20% increase in rescue beta-agonist use can be noted more than a day earlier than 20% change in PEF and almost 5 days earlier than a change in nighttime symptoms – a frequently used indicator of worsening. Although the rate of change was statistically similar, differences can be seen in onset.
This helps us to identify an opportunity to intervene with therapy to stop the exacerbation before it takes hold.
References:
Tattersfield: Am J Respir Crit Care Med 160:594–599, 1999 20
-15
-10 -5 5 10 15
Days (before and post-exacerbation)
Tattersfield: Am J Respir Crit Care Med 160:594–599, 1999

48. Self-Management vs. Usual Care RR (95% CI)
Hospitalisations
ER Visits
Unscheduled Dr Visits
Days off Work
Nocturnal Asthma
By giving patients robust asthma action plans, a number of benefits were evident; these included fewer hospitalisations, ER visits, unscheduled GP visits, days off work and nocturnal asthma.
Favours Self-Management
Gibson PG, Couglan J, Wilson AJ et al. Cochrane Library 2000
Abramson MJ, Bailey MJ, Couper FJ et al. Am J Respir Crit Care Med 2001

50. Statin efficacy in primary prevention
Primary outcome measures: Outcome measure RR (95%CI)
All-cause mortality (0.73 to 0.95)
Fatal and non-fatal CHD events 0.72 (0.65 to 0.79)
Fatal and non-fatal CVD events 0.74 (0.66 to 0.85)
Fatal and non-fatal stroke events 0.78 (0.65 to 0.94)
Combined endpoint (0.61 to 0.79)

Taylor F, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD DOI: / CD pub4.

51. Involving patients in treatment decisions
NICE recommends that people should be offered information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that:
presents individualised risk and benefit scenarios
presents the absolute risk of events numerically
uses appropriate diagrams and text.

52. 20% 10 year CV risk
20 out of 100 people will have a CV event in the next 10 year

53. If 100 people take a statin for 10 years 5 will be saved from having a CV event (NNT = 20)
These people will be saved from having a CV event because they take a statin
These people will have a CV event, whether or not they take a statin

54. 50% 10 year CV risk

55. 6. Keep the treatment as simple as possible
Once or twice daily if possible
Stop medicines that are not needed.

56. Principles of Conservative Prescribing. Arch Intern med 2011: Sep 12.
Seek non drug alternatives
Consider underlying treatable causes rather than treating symptoms.
Prevention rather than focusing on symptoms
Use the test of time as a diagnostic and therapeutic trial.
Avoid frequent switching to new drugs without clear, compelling evidence-based reasons.

57. Principles of Conservative Prescribing. Arch Intern med 2011: Sep 12
Be skeptical about individualising therapy
Whenever possible start treatment with only one medicine at a time
Have a high level of suspicion for ADRs
Educate patients about possible ADRs
Be alert to clues that you may be treating or risking withdrawal symptoms.

58. 7. Stop things that don’t work or are no longer needed
Why is this hard to do?
Evidence of benefit subjective
Fear that might cause harm
Placebo and placebo “by proxy” effect
Perception undermining a colleague
Admission of failure
Collusion of anonymity
Passive or active avoidance
Prescriber distracted by other issues

59. How to address these factors.
Evidence of benefit subjective
Fear that might cause harm
Placebo and placebo “by proxy” effect
Perception undermining a colleague
Admission of failure
Collusion of anonymity
Passive or active avoidance
Prescriber distracted by other issues

60. Long term antidepressant prescribing is common
Petty D, et al. Prevalence, duration and indications for prescribing of antidepressants in primary care. Age and Ageing 2006.

61. 8. Review and monitor
Medication review is a structured, critical examination of a patient's medicines with the objective of :
reaching an agreement with the patient about treatment,
optimising the impact of medicines,
minimising the number of medication-related problems and
reducing waste.

62. Aims of medication review
Optimising the treatment regimen
Is the medicine needed?
Is it working?
Is the dosage evidence based?
Does the patient have any under-treated conditions?
Does the patient have any untreated problems

63. Aims of medication review
Identifying problems
Are the medicines being ordered?
Is the patient able to take it?
Is the medicine interacting with other medicines?
Is the medicine contraindicated?
Are there any adverse drug reactions (ADRs), either reported by the patient or evident from tests?

64. Aims of medication review
Patient’s views and preferences
Does the patient want to take the medicine?
Does the patient have any information needs about their condition and its treatment?
Does the patient understand the purpose of the medicine?
Are the prescription directions clear and practical?

65. Aims of medication review
Waste reduction
Branded to generic
Unwanted medicines
Unneeded medicines
Over ordering

66. Monitoring and review
Monitoring is a watching brief, and only involves intervention in response to pre-set criteria.
It is generally uni-modal, looking at one dimension of the disease or its management.
It is essentially technical and is prescriptive, following a clear protocol.
It does not involve making value judgements.

67. Monitoring and review
Review is a judgement about the success or otherwise of the treatment.
It consists essentially of a professional assessment.
It should be holistic, encompassing the patient and the illnesses as well the diseases and drugs.
Its outcome will consist of decisions about the patient’s progress prognosis and management

68. Any untreated conditions or unaccounted for medicines?
Medical conditions
Type 2 diabetes
Vascular dementia
Rheumatoid arthritis
Asthma
Ischaemic heart disease
Medicines
Adalat La 30
Doxazosin
Fluvastatin
Metformin
Humulin Insulin
Epilim
Sertraline

69. 9. Beware drug-drug and drug condition interactions
It is not possible to remember all contraindications/cautions to drugs
Important examples include:
NSAIDs and peptic ulcer
Beta-blockers and asthma
COCP and venous thrombosis
GP computer system warning are not helpful as to much non specific information
Ensure you have access to full medical record(s)

70. Examples of STOPP drug criteria
NSAID with heart failure
Use of long-term powerful opiates, e.g. morphine or fentanyl as first-line therapy for
mild-moderate pain
TCA with dementia (delirium, fall and fractured femur)
Digoxin >125 μg per day with impaired renal function (digoxin toxicity)
Aspirin with history of PUD without histamine H2 antagonist or PPI (PUD)
Aspirin ≥150 mg/day
Bladder antimuscarinic drugs with dementia
Long-term opiates in those with recurrent falls
Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate–severe COPD

71. Decreasing the total number of prescriptions for these drug-drug combinations or drug-disease combinations would be expected to reduce admissions due to adverse events

72. The STOPP have been applied to a hospital older people population.
STOPP (Screening Tool of Older Peoples Potentially Inappropriate Prescriptions) criteria
The STOPP have been applied to a hospital older people population.
Of 715 admissions
12% of admissions were due to medicines
90% of these were on STOPP criteria drugs

73. Drug interactions
Ensure you know what the patient is prescribed from all sources
Ensure you know what they actually take
Computerised prescribing systems are of some help
Beware home visits

74. 10. Apply the Goldie locks rule to doses
Not too much and not to little.
Start low and go slow
Review regularly
Consider ideal body weight
Consider renal function
Beware interactions that might increase plasma level or drug sensitivity

76. Female aged 20yrs, LBW 60kg, creatinine 90
CrCl (C&G)= 1 x (140-20) x = 80ml/min 90
Female age 85yrs, LBW 60kg, creatinine 90
CrCl (C&G)= 1 x (140-85) x60 = 37ml/min
Female age 85yrs, LBW 50Kg, creatinine 90
CrCl (C&G) = 1 x (140-85) x = 30ml/min
Male age 85yrs, LBW 50kg, creatinine 90
CrCl (C&G) = 1.23 x (140-85) x 50 = 38ml/min

77. Male aged 87yr on simvastatin, 55kg, serum creatinine 121: eGFR reported as 52ml/min
CrCl (C&G) = f x (140-age)xLBW
serum creatinine
f = 1 for females and 1.23 for males
CrCl (C&G) = 29ml/min
BNF app3: simvastatin in doses over 10mg should only be used with caution if CrCl<30ml/min
Using eGFR we would be happy to give simvastatin 40mg but using C&G shows it would be preferable to use an alternative.

78. 10 ideas for safer prescribing
Be familiar with your area of prescribing
Don't prescribe other peoples recommendations unless you are competent and confident
Follow the evidence base
Know what your patient is taking
Involve the patient
Keep the treatment as simple as possible
Stop things that don't work or are no longer needed
Review and monitor
Beware drug-drug and drug condition interactions
Apply the Goldie locks rule to doses