1. Safe Prescribing PHCL 492

2. Safe Prescribing  Key issues for safe prescribing  Ordering Medications  Reducing Prescribing Errors

3. Key issues for safe prescribing  Is prescribing the right decision?  Many patients are very happy to await natural cure rather than risk the side effects of treatment  viral warts  tennis elbow  Lifestyle change can sometimes be a much safer and effective option  Change diet to avoid the risks of statins  Losing weight, exercise, diet to control diabetes and HTN  Prescriber has to weigh up the risk–benefit ratio for the patient

4. Key issues for safe prescribing  Right diagnosis/rational basis for prescribing  Prescribers should always be prepared to reconsider a diagnosis and be able critically to appraise the information on which any diagnosis is made  For example, at what point should chest pain on exercise be labelled angina?  all sorts of preventive procedures that may or may not be appropriate

5. Key issues for safe prescribing  Issuing a safe prescription  Many factors need to be taken into account before prescribing  The age of the patient or sometimes the weight can be important in deciding the correct dose  Female gender:  Are they taking the oral or other contraceptive?  Are they pregnant or trying to conceive?  Are they breast feeding?  Ethnicity can affect the choice of medication in some diseases, and be associated with an increased risk of side effects

6. Key issues for safe prescribing  Issuing a safe prescription  Impairment or loss of function of certain body systems can affect prescribing safety  Reduction in kidney function  Impaired liver metabolism  Other drugs which might interact with the proposed therapy  Other clinical diagnoses which can affect mediation choice  Lifestyle  Cognitive function  Allergies and adverse reactions to drugs

7. Key issues for safe prescribing  Appropriate follow-up  Many of the unnecessary hospital admissions result from inadequate follow-up or monitoring  a patient starting ACE-I should be warned that the first dose may over-lower their blood pressure  People having their dosage of ACE-I adjusted should have their renal function checked as occasionally these medicines can have an adverse effect on kidney function  Considering what may go wrong, or play out differently and planning accordingly

8. Key issues for safe prescribing  Access to up-to-date prescribing information  Patient information  Their wishes, in respect to the proposed prescription.  History from the patient – face-to-face, by telephone and sometimes in writing  The patient’s medical record  A drug dictionary  Access to guidelines  Management of common long-term conditions.  Relevant specialist areas, e.g. end-of-life care.

9. Ordering Medications  as of 2007, most pharmacists still dispense from handwritten medication orders  Illegible Handwriting  Look-Alike Drug Names  Sound-Alike Names  Ambiguous Orders  Abbreviations to Avoid  This was covered in nontechnology interventions lecture

10. Reducing Prescribing Errors  Education and development I. One-to-one educational visits can improve prescribing (academic detailing) II. Training sessions and simulations for students improve confidence in identifying errors, but impacts on error reduction are uncertain III. Education sessions for professionals have reduced prescribing error rates IV. Improvement programs and learning networks have positive outcomes but each varies considerably. I. The process of monitoring and reporting errors may be a key part of this

11. Reducing Prescribing Errors  Expanding professional roles  Pharmacist roles  Pharmacist roles to identify prescribing errors and to stop them reaching patients include:  checking for errors as prescriptions are received at the pharmacy and contacting prescribers for clarification or amendment before filling prescriptions  visiting wards to review charts and provide advice to prescribers about individual patients  reconciling the medicines patients usually take with what they are prescribed in hospital  providing medication reviews upon discharge

12. Checking Medication Orders  US hospital examined how pediatric clinical pharmacists intercept prescription errors.  In total, 78% of potentially harmful prescribing errors were intercepted by pharmacists  A hospital in England examined the impact of pharmacists on preventing prescribing errors at discharge.  Routinely collected data showed that 8% of all medication orders had an intervention by a pharmacist  Pharmacists intercepted 83% of erroneous orders without referring to doctors

13. Checking Medication Orders  Researchers in the Netherlands analyzed the costs and benefits of hospital pharmacy staff detecting prescribing errors.  Over a five-day period, 10% of 3,540 medication orders in two Dutch hospitals contained an error  Estimated benefits amounted to 9,867 Euro compared to 285 Euro in staff time costs

14. Pharmacists on wards  In the Netherlands, a clinical pharmacist reviewed medication orders for patients admitted to the intensive care unit and discussed recommendations during patient review meetings with attending doctors  Over an eight and a half month period, the rate of prescribing errors was lower than before the intervention and preventable adverse drug events were reduced  The intervention cost 3 Euro per monitored day but potentially saved 26 to 40 Euro per monitored day by preventing adverse drug events

15. Pharmacists on wards  pharmacists reviewed prescriptions on the surgical wards at one hospital in Canada and provided group educational sessions for doctors  Doctors accepted 90% of pharmacist recommendations. There was a 9% decrease in drug costs

16. Medicine Reconciliation  Medicine reconciliation by pharmacists has mixed findings but there are some positive trends  In the UK, a pharmacist independent prescriber completed systematic medicine reconciliation in ER and initiated an inpatient prescription chart.  Medicine reconciliation completed within 24 hours of admission increased from 50% to 100% and prescription chart initiation in ER increased from 6% to 80%  The prescribing error rate was reduced from 3.3 errors to 0.04 errors per patient  A cost analysis of five different strategies for preventing medication errors at hospital admission used models and previous studies  Pharmacist reconciliation of medicines was found to be cost effective.

17. Pharmacist Discharge Services  In the Netherlands study examined the effect of pharmacist discharge service on medication discrepancies and prescription errors in people with HF  The pharmacist discharge service was associated with fewer medication discrepancies and prescription errors at one- month follow up (39% versus 68% of people in the control group)

18. Reducing Prescribing Errors  Tools  E-prescribing systems have been found to reduce prescribing errors, though not all studies are positive  There are mixed findings about alerts and prompts  Human factors issues such as the design of systems, workflow, alert type and context may be key success factors when implementing tools to reduce prescribing errors

19. Reducing Prescribing Errors  Tools  Standardized medication charts  In Australia, a standard medication chart was developed for recording prescribing and administration of medication in hospital  Before and after audits in five sites found the prescribing error rate decreased from 20% of orders per patient to 16%  After preliminary testing, the standardized medication chart was rolled out to 22 Australian hospitals. Prescribers were educated and baseline audit findings were presented when the chart was introduced  Prescribing errors decreased by almost one third

20. Summary  Interventions are needed at three levels to improve prescribing: I. improve, the training, and test the competence, of prescribers II. Control the environment in which prescribers perform in order to standardize it, have greater controls on riskier drugs, and use technology to provide decision support III. Change organizational cultures, which do not support the belief that prescribing is a complex, technical, act, and that it is important to get it right