Prescribing Skills Assessment Training Workshop

Prescribing Skills Assessment Training Workshop
PSA Question item styles Communicating Information, Calculation Skills, Adverse Drug Reaction and Drug Monitoring Lynne Bollington Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

Prescribing Skills Assessment – Format
Station Description Marks Comments 1 Prescribing 1 10 1 question item of 10 marks 2 Prescribing 2 3 Prescription Review 1 8 2 question items of 4 marks each 4 Planning Management 5 Communicating Information 6 3 question items of 2 marks each Drug Calculation Skills 4 question items of 2 marks each 7 Prescribing 3 Prescribing 4 9 Prescription Review 2 Adverse Drug Reactions 11 Drug Monitoring 12 Data Interpretation TOTAL MARKS 100 Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

COMMUNICATING INFORMATION
Competencies Reasoning and judgement Deciding what are the most important bits of information that should be communicated to patients to allow them to choose whether to take the medicine and to enhance its safety and effectiveness. Measurable action Selecting the information that is most appropriate. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

This question type will present: a clinical scenario where a patient needs information about their medicines a request to identify the most important bits of information that they would give to the patient This will involve: selecting bits of information that would be of real benefit and disregarding others that would be less appropriate or important Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

Good Communicating Information question items should: be based on a clinical scenario where a patient is about to start taking a medicine or has other reasons to ask for information that is relevant to its effectiveness and safety express information options using patient-friendly language avoiding medical and scientific jargon Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

Case presentation A [age] -year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

Good Communicating Information question items should: be based on a list of 5 information options contain sufficient information to allow a competent candidate to select the 2 best options unambiguously contain 3 distracting options that, while plausible, are clearly less appropriate than the correct answers in relation to the clinical scenario Question Select the TWO most appropriate information options that should be communicated to the [patient/mother/staff nurse/GP] from the list provided. (mark them with a tick) Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

INFORMATION OPTIONS ID Answer box Communicating Information Item
This question item is worth 2 marks You may use the BNF at any time Case presentation A [age] -year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] [Authors should try to adhere to this general layout but there is room for flexibility – the presentations should be fairly brief] INFORMATION OPTIONS A Option A ☐ B Option B C Option C D Option D E Option E Identify the correct answers by placing a tick in the column on the right Place 5 plausible information options in the boxes provided, describing each with clarity Question Select the TWO most appropriate information options that should be communicated to the [patient/mother/staff nurse/GP] from the list provided. (mark them with a tick) Answer box Option A Justification Write a brief justification in this box Option B Option C Option D Option E Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

INFORMATION OPTIONS ID Answer box Communicating Information Item
This question item is worth 2 marks You may use the BNF at any time Case presentation A 36-year-old man has been admitted with a deep vein thrombosis (DVT) following recent orthopaedic surgery to his knee. On the ward round he has been given the result of his Doppler ultrasound (positive) and told that he will require treatment with warfarin. He is already being given low-molecular-weight heparin injections. After the ward round, warfarin must be prescribed and the patient provided with appropriate information about the new treatment. INFORMATION OPTIONS A all warfarin 3 mg tablets are blue  B the major adverse effect of warfarin is bleeding C warfarin is better tolerated if given twice daily ☐ D warfarin therapy increases the risk of heart attack E weekly blood tests will be required throughout treatment Question Select the TWO most appropriate information options that should be communicated to the patient. (mark them with a tick) Answer box Option A Justification All warfarin tablets (0.5 mg, 1 mg , 3 mg and 5mg) are colour-coded to aid recognition and estimation of dose. Option B Warfarin is an anticoagulant that carries a significant risk of bleeding. This risk is reduced if the INR is regularly monitored. Option C Warfarin is no better tolerated if given twice daily compared to the normal once daily dosing regimen. Option D There is no evidence that warfarin increases the risk of myocardial infarction. Option E Frequent blood tests are necessary in the early weeks of treatment but once the results are stable the tests are required less often. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

CALCULATION SKILLS Competencies
Reasoning and judgement Making an accurate drug dosage calculation based on numerical information Measurable action Recording the answer accurately with appropriate units of measurement Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

CALCULATION SKILLS This question type will present:
a scenario that requires an accurate calculation of the dose or rate of administration of a medicine Typically this question type will involve: interpreting the problem correctly using basic arithmetic skills to derive the correct answer Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

CALCULATION SKILLS Examples of potential scenarios might include:
identifying the correct number of tablets or volume of medicine to achieve a required dose making necessary dose adjustments based on weight or body surface area calculation of appropriate infusion rates or volumes for administration of medicines in an infusion pump testing the candidate’s ability to recognise and convert different expressions of drug doses and concentrations Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

CALCULATION SKILLS Good Calculation Skills question items should:
be based on a very brief clinical scenario require a calculation to be made in order to select a safe and effective dose or to plan the patient’s treatment in some other way Case Presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. You are required to give a dose of ...etc. The patient weighs … [The case presentations should be fairly brief – 2 or 3 sentences] Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

CALCULATION SKILLS Good Calculation Skills question items should:
contain all the relevant numerical data with standard units and may also contain reasonable distracting data that might require the competent candidate to reject it as irrelevant to the calculation Calculation What is the [total amount/volume/duration/total dose etc.] that the patient [will receive/should be given, etc.] …… ? (Write your answer in the box below) Answer unit Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ID Answer box Calculation Skills Item Case Presentation
This question item is worth 2 marks You may use a calculator at any time Case Presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. You are required to give a dose of ...etc. The patient weighs … [The case presentations should be fairly brief – 2 or 3 sentences] Answer box Correct Answer Write the correct answer with units in this box Working Write a brief justification of the answer in this box, sufficient to explain how to calculate the correct answer Calculation What is the [total amount/volume/duration/total dose etc.] that the patient [will receive/should be given, etc.] …… ? (Write your answer in the box below) Answer unit Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

0.25 ID Answer box Calculation Skills Item Case presentation
This question item is worth 2 marks You may use a calculator at any time Case presentation An 8-month-old boy weighing 9 kg requires a dose of midazolam 2.5 mg to be administered buccally for febrile convulsions. Buccal midazolam liquid is available as a 10 mg/mL solution. Answer box Correct answer 0.25 mL Working The dose of midazolam required is 2.5 mg. The concentration of the solution available is 10 mg/mL. Therefore volume required = 2.5/10 mL = 0.25 mL The weight of the child is irrelevant to the calculation. Calculation What volume of liquid should the patient be given? (Write your answer in the box below) Answer 0.25 mL Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Competencies
Reasoning and judgement Identifying likely adverse reactions of specific drugs, drugs that are likely to be causing specific adverse drug reactions, potentially dangerous drug interactions and deciding on the best approach to managing a clinical presentation that results from the adverse effects of a drug Measurable action Selecting likely adverse reactions of specific drugs, selecting drugs to discontinue as likely causes of specific reactions, avoiding potential drug-interactions and providing appropriate treatment for patients suffering an adverse event Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Good Adverse Drug Reaction question items should: be one of four types (A-D) be based on a list of 5 options (drugs/adverse effects/interactions/actions) relating to the scenario, from which the candidate will be required to select the 2 most appropriate be based on common adverse effects, so that competent candidates are not faced with the need to refer constantly to the British National Formulary Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Type A
This question type will require the candidate to identify likely adverse effects of a specific drug Examples might include the adverse effects caused by commonly prescribed drugs, such as calcium channel blockers, beta-2 agonists, non-steroidal anti-inflammatory drugs, aminoglycoside antibiotics, etc. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Type A
Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] Question Select the TWO adverse effects that are most likely to be caused by this treatment. (mark them with a tick) Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE EFFECT OPTIONS
Adverse Drug Reactions Item – Type A ID ADR101 This question item is worth 2 marks You may use the BNF at any time Case presentation A 67-year-old man has started to take oral morphine (Sevredol®) 10 mg 4-hrly for pain associated with a gastric carcinoma. ADVERSE EFFECT OPTIONS A diarrhoea ☐ B drowsiness  C nausea D palpitations E sweating Question Select the TWO adverse effects that are most likely to be caused by morphine. (mark them with a tick) Answer box Option A Justification Morphine is associated with constipation, not diarrhoea. Option B Morphine acts on opioid receptors in the brain to depress neurotransmission and potentially cause drowsiness. Option C Morphine is a well-recognised cause of nausea and vomiting and is sometimes co-prescribed with anti-emetic drugs. Option D Morphine is associated with the development of palpitations but this is a less common adverse effect than either drowsiness or nausea. Option E Sweating and agitation are phenomena associated with withdrawal of opioid analgesics in dependent patients. They can occur as an adverse effect of morphine but less commonly than either drowsiness or nausea. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Type B
This question type will require the candidate to consider a presentation that could potentially be caused by an adverse drug reaction and identify the medicines most likely to have caused the presentation Examples might include newly recognised renal impairment, hepatic dysfunction, hypokalaemia, urinary retention, etc. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Type B
Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] Question Select the TWO prescriptions that are most likely to be contributing to the [insert adverse effect]. (mark them with a tick) Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

PRESCRIPTION OPTIONS ID Answer box
Adverse Drug Reactions Item – Type B ID ADR201 This question item is worth 2 marks You may use the BNF at any time Case presentation A 67-year-old man with chronic heart failure is admitted to hospital after his GP notices that his serum creatinine concentration has become acutely elevated from its baseline value of around 150 µmol/L (60–110) to 450 µmol/L. PRESCRIPTION OPTIONS A aspirin 75 mg orally daily ☐ B bisoprolol 5 mg orally daily C digoxin 125 micrograms orally daily D furosemide 160 mg orally daily  E lisinopril 40 mg orally daily Question Select the TWO prescriptions that are most likely to be contributing to the acute deterioration in renal function. (mark them with a tick) Answer box Option A Justification Aspirin is a non-steroidal anti-inflammatory drug but at this low cardiovascular preventative dose it is unlikely to have any significant effect on renal function. Option B Bisoprolol has little impact on renal function Option C Digoxin is a drug that has to be used with care in patients with renal impairment but is not, itself, a cause of renal impairment. Option D Furosemide is a powerful loop diuretic, use of which can lead to dehydration with consequent impairment of renal function. Option E Lisinopril is an ACE inhibitor that interferes with the intra-renal renin-angiotensin system, which protects renal function when blood flow is reduced. Therefore, this class of drug is associated with renal impairment in vulnerable patients. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Type C
This question type will require the candidate to consider a presentation where there are potential interactions between medicines currently being prescribed to a patient and identify those that might be clinically important. Examples might include interactions such as warfarin–statins, NSAIDs–ACE inhibitors. etc. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Type C
Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

PRESCRIPTION OPTIONS ID Answer box
Adverse Drug Reactions Item – Type C ID ADR301 This question item is worth 2 marks You may use the BNF at any time Case presentation A 33-year-old woman is being reviewed by her GP. Her current regular prescriptions are listed (right). PRESCRIPTION OPTIONS A fluoxetine 20 mg orally daily ☐ B folic acid 5 mg orally daily C norethisterone 350 micrograms (Micronor®) orally daily D propranolol 40 mg orally 8-hrly  E salbutamol inhaler 200 micrograms as required Question Select the TWO prescriptions that are most likely to interact with each other. (mark them with a tick) Answer box Option A Justification Fluoxetine does not interact with the other drugs. Option B Folic acid has few significant interactions. Option C Norethisterone is a progestogen that does not have a significant interacttion with any of the other drugs listed. Option D Propranolol is a beta-adrenoceptor blocking drug that is contraindicated in asthma because it has the potential to block beta2-receptors in the bronchi and precipitate bronchospasm. Option E Salbutamol is a bronchodilator because it activates beta2-receptors. It can also induce tremor and anxiety. Therefore, it has an important potential interaction with propranolol. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Type D
This question type will require the candidate to consider a presentation where a patient is suffering an adverse drug event and decide on the appropriate course of action. Examples of adverse events might include acute anaphylaxis, excessive anticoagulation, drug-induced hypoglycaemia, diuretic-induced dehydration. etc. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

ADVERSE DRUG REACTION Type D
Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] Question Select the TWO most appropriate options for the management of this adverse drug event. (mark them with a tick) Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

MANAGEMENT OPTIONS ID Answer box Adverse Drug Reactions Item – Type D
ADR000 This question item is worth 2 marks You may use the BNF at any time Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] [Authors should try to adhere to this general layout but there is room for flexibility – the presentations should be fairly brief but there should be sufficient information about the patient and adverse event for the candidate to clearly identify the 2 most appropriate actions at this point] MANAGEMENT OPTIONS A Option A ☐ B Option B C Option C D Option D E Option E Identify the correct answers by placing a tick in the column on the right Place 5 plausible management options in the boxes provided including the relevant dose and route Question Select the TWO most appropriate options for the management of this adverse drug event. (mark them with a tick) Answer box Option A Justification Write a brief justification in this box Option B Option C Option D Option E Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

MANAGEMENT OPTIONS ID Answer box Adverse Drug Reactions Item – Type D
ADR401 This question item is worth 2 marks You may use the BNF at any time Case presentation A 75-year-old man is having a colonoscopy and, because of marked anxiety, has been given three doses of midazolam 1 mg IV. Five minutes after the last injection his breathing is noted to be very shallow (RR 6/min) and the O2 sat is 86% on air. A nasopharyngeal airway is inserted. MANAGEMENT OPTIONS A adrenaline (epinephrine) 500 micrograms IM ☐ B flumazenil 200 micrograms IV  C hydrocortisone 200 mg IV D naloxone 400 micrograms IV E oxygen high flow (targeted to O2 sat 95%) Question Select the TWO most appropriate options for the immediate management of this adverse drug reaction. (mark them with a tick) Answer box Option A Justification This will not address the primary problem, which is oversedation caused by midazolam. Adrenaline is effective in anaphylaxis and cardiovascular collapse. Option B Flumazenil is a benzodiazepine antagonist drug that can be used to treat an overdose of midazolam as well as to reverse sedation with other benzodiazepines. Option C Hydrocortisone and other corticosteroids will have no impact on respiratory depression. Option D Naloxone is a mu opioid receptor antagonist but is unlikely to be of any benefit when respiratory depression seems likely to be secondary to midazolam Option E The delivery of high flow oxygen is a critical step in the treatment of respiratory depression and low O2 saturation. The oxygen therapy should be targeted to achieve a specific saturation. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

DRUG MONITORING Competencies
Reasoning and judgement Deciding on how to monitor the beneficial and harmful effects of medicines Measurable action Identifying the appropriate methods of assessing the success or failure of a therapeutic intervention Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

DRUG MONITORING This question type will involve:
a scenario that involves making judgements about how best to assess the impact of treatments that are ongoing or are being planned demonstrating an understanding of how to plan appropriate monitoring for beneficial and harmful effects The correct course of action may involve: taking blood samples at the right time deciding which is the most appropriate assessment of outcome deciding on the timing of those measurements Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

DRUG MONITORING Good Drug Monitoring question items should:
be based on a clinical scenario where a patient is starting to take a treatment and the candidate is being asked to identify the best ways of monitoring its beneficial or adverse effects Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

DRUG MONITORING Good Drug Monitoring question items should:
be based on a list of 5 monitoring options relating to the treatment identified, from which the candidate will be required to select the 2 most appropriate contain 3 distracting options that, while plausible, are clearly less appropriate in relation to monitoring the beneficial or adverse effects of the treatment than the correct answers Question Select the TWO most appropriate monitoring options to assess the [beneficial/adverse] effects of this treatment. (mark them with a tick) Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

MONITORING OPTIONS ID Answer box Drug Monitoring Item
TDM000 This question item is worth 2 marks You may use the BNF at any time Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom that might be used as the focus for one of the questions] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] [Authors should try to adhere to this general layout but there is room for flexibility – the presentations should be fairly brief but identify the treatment that is being started, the therapeutic indication and sufficient information about the patient for the candidate to be able to identify the best monitoring options] MONITORING OPTIONS A Option A ☐ B Option B C Option C D Option D E Option E Identify the 2 correct answers by placing a tick in the column on the right Place 5 plausible monitoring options in the boxes provided, describing each with clarity Question Select the TWO most appropriate monitoring options to assess the [beneficial/adverse] effects of this treatment. (mark them with a tick) Answer box Option A Justification Write a brief justification in this box Option B Option C Option D Option E Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

MONITORING OPTIONS ID Answer box Drug Monitoring Item
TDM001 This question item is worth 2 marks You may use the BNF at any time Case presentation A 71-year-old woman is admitted with severe community-acquired pneumonia. She has been coughing up thick green sputum for 2 days. Examination reveals that she is pyrexial, tachypnoeic, and has crackles at the right lung base. A chest X-ray confirms a right lower lobe pneumonia. Treatment with co-amoxiclav 1.2 g IV 8-hrly is initiated. MONITORING OPTIONS A chest X-ray appearance ☐ B disappearance of basal crackles C respiratory rate  D sputum colour E temperature Question Select the TWO most appropriate monitoring options to assess the beneficial effects of this prescription in the first three days of treatment. (mark them with a tick) Answer box Option A Justification The chest X-ray appearance is unlikely to resolve in the early stages of treatment. Option B The auscultatory finding of basal crackles at the base of the lung will take several days to resolve. Option C Successful treatment of the pneumonia will improve gas exchange and the hypoxia and reduce the respiratory rate. Option D Sputum colour is a poor guide to the success of treatment for pneumonia. Option E Successful treatment of her pneumonia is likely to lead to a fairly rapid reduction in her temperature. Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

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