Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "10 top tips for safer prescribing and review of medicines Dr Duncan Petty Lecturer Practitioner School of Health Care, University of Leeds RCN Advanced."— Presentation transcript:

1

2 10 top tips for safer prescribing and review of medicines Dr Duncan Petty Lecturer Practitioner School of Health Care, University of Leeds RCN Advanced Nurse Practitioner Forum conference 2011

3 10 top tips for safer prescribing and review of medicines Dr Duncan Petty Lecturer practitioner, University of Leeds Director, Prescribing Support Services Ltd

4 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

5 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

7 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

8 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.

9 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

10 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

11 10 ideas for safer prescribing 1.Be familiar with your area of prescribing 2.Don't prescribe other peoples recommendations unless you are competent and confident 3.Follow the evidence base 4.Know what your patient is taking 5.Involve the patient 6.Keep the treatment as simple as possible 7.Stop things that don't work or are no longer needed 8.Review and monitor 9.Beware drug-drug and drug condition interactions 10.Apply the Goldie locks rule to doses

12 1.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.

13 Warfarin or dabigatrin for stroke reduction in atrial fibrilliation?

14 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?

15 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?

16 Asthma death girl 'was let down' BBC News 24 th 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.

17 Inhaled steroids in children

18 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.

19 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

20 Shifting through the evidence Journal of Family Practice 1994;38: Frequency commonFrequency 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 19

21 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.”

22 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

24 Surrogate markers –HbA1c –Blood pressure –Cholesterol –Bone density

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

26 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.

27 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.”

28 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

29 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,

30 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;

31 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

32 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 % of patients studied. Lowe CJ et al. Br.J.Clin Pharmacol 2000;50:172-5 and Bikowski R et al. JAGS 2001:49 (10) % of drug-related problems were only recognised through a patient interview. Jameson JP & Van Noord GR. Ann Pharmacother. 2001;35:

33 Reconciliation is not enough

34 Involve the patient 5. Involve the patient or carer

35 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.

36 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.

37 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.

38 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.

39 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.

40 Task 1: Rates of non- Compliance ConditionRate of non-compliance (%) Contraception8 Asthma20 Epilepsy30-40 Hypertension40 Diabetes40-50 Arthritis55-71

41 What level of adherence? 2 DiseaseDesired outcomeAdherence rate needed HypertensionNormotension80% (50% not sufficient) MISurvival at 1 year>75% 3x as likely HIVEfficacy/resistance>95%

42 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?

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

44 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.

45 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

46 A high % of patients change their own treatment due to this asthma variability Total (n=517) 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) Reliever once a day, no other medication (n=169) Current asthma treatment 020%30%60%50%80%10%40%70% Haughney J, Barnes G, Partridge M, et al. Prim Care Resp J 2004; 13: 26-35

47 A high % of patients who thought their asthma was under control were experiencing regular symptoms Percentage of respondents who thought that their asthma was under control, related to the frequency of asthma symptoms Total (n=517)Every day – both day and night (n=120) 2-3 times a week (n=127) Every day – either during the day or during the night (n=92) Once a week (n=86) Once a month (n=50) Less than once a month (n=42) 100% 80% 60% 40% 20% 0 Haughney J, Barnes G, Partridge M, et al. Prim Care Resp J 2004; 13: 26-35

48 % change Days (before and post-exacerbation) Rescue   Morning PEF Nighttime symptoms (most specific indicator) Profile of 425 severe exacerbations Tattersfield: Am J Respir Crit Care Med 160:594–599, 1999

49 Hospitalisations ER Visits Unscheduled Dr Visits Days off Work Nocturnal Asthma RR (95% CI) Self-Management vs. Usual Care 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

51 Statin efficacy in primary prevention Primary outcome measures:Outcome measureRR (95%CI) All-cause mortality0.83 (0.73 to 0.95) Fatal and non-fatal CHD events0.72 (0.65 to 0.79) Fatal and non-fatal CVD events0.74 (0.66 to 0.85) Fatal and non-fatal stroke events0.78 (0.65 to 0.94) Combined endpoint 0.70 (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.

52 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.

53 20% 10 year CV risk 20 out of 100 people will have a CV event in the next 10 year

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

55 50% 10 year CV risk

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

57 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.

58 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.

59 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

60 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

61 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.

62 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.

63 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

64 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?

65 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?

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

67 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.

68 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

69 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

70 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)

71 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 Examples of STOPP drug criteria

72 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

73 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 STOPP (Screening Tool of Older Peoples Potentially Inappropriate Prescriptions) criteria

74 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

75 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

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

78 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.

79 10 ideas for safer prescribing 1.Be familiar with your area of prescribing 2.Don't prescribe other peoples recommendations unless you are competent and confident 3.Follow the evidence base 4.Know what your patient is taking 5.Involve the patient 6.Keep the treatment as simple as possible 7.Stop things that don't work or are no longer needed 8.Review and monitor 9.Beware drug-drug and drug condition interactions 10.Apply the Goldie locks rule to doses


Download ppt "10 top tips for safer prescribing and review of medicines Dr Duncan Petty Lecturer Practitioner School of Health Care, University of Leeds RCN Advanced."

Similar presentations


Ads by Google