Presentation on theme: "The Prescribing Pyramid"— Presentation transcript:
1 The Prescribing Pyramid Pyramids – The pyramids at GizaUnder a CC BY-NC-SA 2.0 licenseFacilitators notesThis activity has 2 sections:This presentation on the prescribing pyramid (1 hour)The activity (1.5 hours)Target audienceNursesMidwivesPharmacistsChiropodistsPhysiotherapistsJunior doctors or medical studentsGood prescribing is not easy I hope that this session will help you with you prescribing decisions. The process of writing a prescription starts a chain reaction that will have an impact on the patient, possibly their family, the prescriber and the NHS.Kimberley Tordoff
2 Aim of the sessionTo appraise the use of the prescribing pyramid in relation to non medical prescribing decisions
3 Learning Outcomes By the end of the session learners will be able to KnowledgeDescribe the seven principles of good prescribingDescribe the concept of the prescribing pyramidSkillspractice using the prescribing pyramidchallenge other members of the multi-disciplinary group on decisionsAttitudesContinue to build up relationships with their peers through group work
4 The prescribing pyramid ReflectRecord KeepingReviewNegotiate a contractChoice of productWhich strategyConsider the patientThe process to prescribe or not to prescribe is a complex one that needs many factors considering before that all important piece of paper is given to the patient, the prescribing pyramid is a process that may help you so that you are sure all the bases have been covered.
6 1. Consider the patient… The Consultation Prepare as much as you can & establish rapportIdentify reasons for consultExplore the patientsIdeas,Concerns andExpectations of the problem (ICE)Obtain essential informationImpact of problem of the problemDifferential diagnosesRe evaluate information, ensure shared understanding, consider more tests, and interpret results for diagnosisDecide treatment options discuss with patient, Q&ASummarising, terminating the consultation, writing-upIn 70% of cases the diagnosis will be evident just from a clinical history alone before tests or examination takes place. A good history facilitates good prescribing. Each consultation should have a structure bit it shouldn’t be like a straitjacket These are the vital elements that need to be coveredRapport..observe the pt s demeanour, put at ease, convey warmth and confidence. In reality we don’t take a history we make a history as it is a two way process.
7 1. Consider the patient WWHAM! What's Wham got to do with it? Who is it forWhat are the symptomsHow long have the symptoms been presentAny action takenMedicationWhat information would you want to know about the patient/symptomsNMC picked up on this mnemonic as it had been used by pharmacists when helping them advise people buy medications. It isn’t robust enough to use in isolation, but if incorporated into the assessment it makes sure that medication history is taken; POMs, OTC, Herbal, allergies, patients tend not to tell you about these as they don’t think that they are important. Examine the holistic needs of the patient looking at the determinants of health. Patients will often omit to tell you about OTC preps or herbal meds, but need to know for contraindicated drugs. Discuss illegal drug meds
8 The determinants of Health Age, sex, hereditary factorsLifestyle factorsSocial & community networksLiving & working conditionsSocio-economic, cultural & environmental conditionsDahlgren & Whitehead 1991The pts medical and social history needs to be taken, a thorough needs assessment may show that non drug therapy may be indicated. Allergies need to be identified and recorded
9 Medications Drug History and Allergies Ask patient to list medications they are on, or show their repeat prescription, or bring in their meds.Ensure you have a written record in your notes of the name, dose, frequency and route.Are they actually taking them as prescribed?Enquire about Over The Counter (OTC), herbal and illicit…you may be shocked!Any allergies or reactions to meds or foods or environmental factors and record them and any treatment given.Really important part of prescribingPatients symptoms may be as a result of the medications they are on!Women often do not volunteer the pill as they don’t see it as medicationThey may also not include inhalers, creams, patches or pessaries, eye drops….ask specifically
10 2. Strategy Is diagnosis established? Is there a need to prescribe? Is referral elsewhere indicated?What does the patient expect?A prescription should only be given when there is a genuine need. When the patient presents it is important to bear in mind that other treatment options need to be considered. Only prescribe when there is a genuine need, patients may want to have a prescription for other reasons…legitimate a sick role, a friend recommended it, gain attention, give or sell to someone else. Patient expectations for medication. Could there be alternative treatments… TENSHas the pt presented with serious or sinister signs that need attention from another person
12 Safety IssuesFor any given therapeutic intervention, the potential benefits of the treatment must always be balanced against the known safety concerns.ADRs account for 5% of all hospital admissions and are associated with significant M and M risks
13 Avoiding Adverse Drug Reactions Use as few concurrent drugs as possibleUse the lowest effective doseCheck if patient pregnant or breast feedingIs the patient at extremes of life?Do you know all of the drugs that the patient is takingCheck for Over The Counter medicinesDrug allergies or previous reactions to medications
14 4. Negotiate Concordance Compliance Medicines adherence DANCING NOT FIGHTING! Enables the pt to have a role in the decision making process. . It is a shared contract between the prescriber and patient. It replaces the term compliance which is seen as a negative concept where the patient simply does as they are told.For concordance to occur the patient needs to know what the drug is for, side effects, how long it takes to work, efficacy, when to get advice and from where, potential problems and what to do needs to be talked through with the patient. Patient leaflets.Add image of handshake and dancers
15 Review Where When How Who Regular review of the patient will establish whether the meds prescribed is safe and effective and acceptable. Always have a plan BPolicy on repeat prescriptions variable, repeat prescribing without review will be wasteful and potentially dangerous. make sure the pt knows who to contact and when
16 Record Why is it important What are the barriers to this in practise Good records are essential, a professional requirement from the NMC enter prescription details into records asap in the appropriate records, best practice 24 hours in community to amend gp recordsInclude date, name of prescriber, name of drug, in fact everything that is on the script plus a record of the consult. Your records need to support your decision making process in case of legal comeback, but also to help fellow clinicians in future evaluation of the patient.
17 Record Keeping Guidelines AccurateLegibleUnambiguousContemporaneousRelevantEnough to enable other professionals to provide effective careDated, timed and signedPractitioners must not tamper with original records in any wayElectronic records are clearly attributableKept securely (NMC,2008)Integral part of professional practiceIs not an optional extra to be omitted if you are short of timeIs a reflection of your standard of practice
18 Reflect On your prescribing decision On the episode as a whole Discuss with colleaguesCode of conduct states that we should maintain and improve our professional knowledge and competence and by reviewing and reflecting we can do this almost on a subliminal level after a while. Periodic review with co workers, discuss with pharmacy, pact data prescribing analysis and cost…allows the individual to compare with others and whether you adhere to local policies
19 ReferencesDahlgren & Whitehead (1991) Social Model of Health Nursing & Midwifery Council ( NMC) (2008) The code: Standards of conduct, performance and ethics for nurses and midwives May London NMC
20 Note for facilitator Divide the class into inter-professional groups Now proceed to Activity on prescribing pyramid
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