Bendigo Health Pharmacy Department Inpatient prescribing

Patient identification Patient identification is essential for safe drug prescribing and administration Patient identification must be visible on all sections on the drug chart – FRONT & BACK 111111 BLOGGS, Mr. Joe 26/10/1939 1 Cumming St Male, 69 years, 3 months Bendigo VIC, 3550 Ward: MED Ph: 5454 9003 MC:20893525471 Public- Eligible AMU- Acute Medical unit Adm: Thursday 7th January 2016 GP: dr SMITH John, Medcial medical Clinic Only 28% of charts had correctly completed patient ID Patient must have the identification labels on all drug drug charts (front and back) Prescribe must print the patient’s name underneath the label to verify that both the ID label & drug orders relate to the correct patient. This will reduce risk of wrong ID label being placed on the chart. Needs to be completed front & back of drug charts Weight should be documented here. It is important clinical information, vital to calculating and confirming doses of certain medicines, particularly for paediatrics and chemotherapy patients as the BSA is needed for accurate dose calculation. Patients should have their weight recorded on at least 1 of their current drug charts (if there are multiple charts). 21% of drug charts incomplete – not filling in the back of chart – or not hand writing the name under the label 75kg Joe Bloggs

Allergies and Adverse Drug Reaction (ADR) Alerts Medical officers, registered nurses and pharmacists are obliged to complete ADR details for patients – when asking a patient use terms such as ‘allergy or side effects’ Once information has been verified and documented, the person documenting the information must SIGN, DATE and PRINT THEIR NAME When documenting any additional information – the person adding the information must initial the designated area If a previous ADR exists, list the following: Drug name Reaction details (e.g. rash, diarrhoea, anaphylaxis) Date of reaction (if possible) Who recorded the information If the patient is not aware of any perivious ADRs, then the nil known box should be ticked. If the patient is unable to communicate this information, the unknown box should be ticked. The person documenting the information must sign, print their name, and date the entry 37.36% - failed as ADR either hasn’t been signed and printed, or failed to include reaction type

Allergies and Adverse Drug Reaction (ADR) Alerts Ibuprofen GI bleed (2014) T.Smith T.Smith 07/01/2016 Medical officers, registered nurses and pharmacists are obliged to complete ADR details for patients – when asking a patient use terms such as ‘allergy or side effects’ Once information has been verified and documented, the person documenting the information must SIGN, DATE and PRINT THEIR NAME When documenting any additional information – the person adding the information must initial the designated area If a previous ADR exists, list the following: Drug name Reaction details (e.g. rash, diarrhoea, anaphylaxis) Date of reaction (if possible) Who recorded the information If the patient is not aware of any perivious ADRs, then the nil known box should be ticked. If the patient is unable to communicate this information, the unknown box should be ticked. The person documenting the information must sign, print their name, and date the entry 37.36% - failed as ADR either hasn’t been signed and printed, or failed to include reaction type 35% OF ADRS WERE NOT completed properly

Regular Medication orders A drug order is only valid if: All patient identification is completed The prescriber enters all of the following: Date Generic name (active ingredient name) Slow release box is ticked when applicable Route Dose Dose calculation (paediatric charts only) Frequency and administration times Indication Prescriber signature, print name and contact (pager number) FILL IN ALL THE BOXES

32% of drug orders had some sort of error prone abbreviation DANGEROUS ABBREVIATIONS DO NOT USE IN MEDICATION ORDERS ROMAN NUMERALS ARE NOT PERMITTED Large lists of abbreviations can be hard to memorise. This is a short list of the DANGEROUS abbreviations which we should NOT use Error Prone Abbreviation   Intended meaning Misinterpretation Correct Abbreviation Ug, mcg or μg microgram Mistaken for milligram when handwritten  microgram or microg  U or u unit Mistaken as the numbers ‘0’ or ‘4’, causing a 10-fold overdose or greater (e.g. 4U seen as ‘40’ or 4u seen as ‘44’). unit(s) OD, od or d Once a day Once daily Mistaken for twice a day d is easily missed daily or the specific time QD or qd Every day Mistaken as qid (four times a day) daily Q4h Every 4 hours Every 4 hrs, 4 hourly, 4 hrly SC subcutaneous Mistaken for sublingual subcut or subcutaneous SL or S/L sublingual Mistaken for SC & interpreted as subcutaneous subling or sublingual No zero before decimal point (e.g. .5mg)  0.5mg Misread as 5mg  0.5 mg or write 500 microgram or 500 microg Trailing zero after decimal point (e.g. 5.0mg) 5mg Misread as 50mg Do not use trailing zero after decimal points or after whole numbers 32% of drug orders had some sort of error prone abbreviation

VTE Prophylaxis Guide to accessing IDEA3S Printed Version 1. 7th May 2012 Guide to accessing IDEA3S MEDICAL ADULT VTE Risk Screening Tool (see full policy on PROMPT) LMWH = low molecular weight heparin UFH = low dose unfractionated heparin IPC = intermittent pneumatic compression GCS = graduated compression stockings Acute on chronic lung dis. Acute on inflammatory dis. Cancer Decompensated heart failure Acute spinal cord injury History of VTE Active cancer Age > 60years Myocardial infarct Until resolution of acute medical illness or hospital discharge LMWH or UFH Withhold 1st dose 24 hours post thrombolysis LMWH DURATION PROPHYLAXIS FEATURES Ischaemic stroke Moderate High RISK Immobility Thrombophilia Oestrogen therapy Obesity Medical conditions with additional VTE risk factors: Acute inflammation Pregnancy or puerperium Acute infection Family history of VTE Consider Pharmacy Department tel: 9003 Printed version 1. 01/05/2014 SURGIAL ADULT VTE Risk Screening Tool (see full policy on PROMPT) Until discharge Consider LMWH or UFH Consider GCS Pregnancy/ puerperium 5 – 10 days or fully mobile GCS +/- IPC Any surgery with prior VTE &/or active cancer 5 – 10 days or fully mobile (cancer surgery consider 28 days) Major surgery and age > 40 years Major surgery definition: All intraabdominal including laparoscopic Duration >45 mins See Orthopaedic VTE Policy Major orthopaedic trauma Hip fracture surgery Hip or knee arthroplasty Major trauma Other surgery with additional VTE risk factors:

VTE Prophylaxis 11% OF charts had vte risk assessment completed 14/01 The VTE prophylaxis section in the medication chart is designed to improve the documentation of VTE risk assessment and increase the prescription of VTE prophylaxis (pharmacological and mechanical) in patients at risk of developing a VTE and in whom prophylaxis is indicated The VTE prophylaxis section is in the regular medications section and is highlighted in red to remind clinicians to assess VTE Risk and Prescribe VTE prophylaxis if indicated 11% OF charts had vte risk assessment completed 14/01 14/01 Enoxaparin 0800 S/Cut 40 mg Daily T.Smith 200

Joe Bloggs’ Medication orders Pre-admission meds Seretide 250/25 ii puffs inh bd Metformin XR 1000mg i tab o morning Hospital initiated meds: Benzylpenicillin 1.2g IV every 6 hours Prednisolone 30mg for 2/7, then 25mg for 2/7 Enoxaparin 40mg sc daily Paracetamol 500mg ii tabs o every 6 hours prn

Regular Medication orders Seretide 250/25 inhale ii puffs bd If the order is recharted –the date on which the order is re-written should be entered on the new order (not the date it was originally prescribed) Seretide 250/25 7/1 08:00 20:00 inh 2 puffs 12 hrly Dose: must be written using metric (e.g. grams, litres and Arabic system (e.g. 1, 2, 3). Always use a zero (0.) before a decimal point but never after the decimal point. If possible it is preferable to state the dose in whole numbers and not decimal ( write 500mg instead of 0.5g or write 125 microg instead of 0.125mg) Don’t use U or IU for units – they can be misread as 0 or 10. always write units in full pneumonia EVERY order must have a signature & NAME PRINTED T Smith 154 Medicine – to be done in generic name. With the exception of combination products – Targin, Seretide, coveram. Be cautious that some combination products (i.e. relatively new ones) aren’t stocked by the hospital – and you may be asked to write them out individually. If you do prescribe in brand name – make sure you know what is in it. Occasionally you see duplicates of orders – Somac vs Pantoprazole Route – avoid dangerous abbreviations – SC vs subcut Dose – to be written out avoid using dangerous abbreviations microg and units Frequency – avoid dangerous abbreviations OD/QD for daily - D Indication – ideally to be written - Prescriber sign & print name – contact details Timing it is the doctors resposnisbility to fill in the timing of the doses – not the nurses – sometimes the nurse fills it in and misses the times. Writing only 8am for bd doses, or specific timing required. Diuretics bd – writing it up at 800 and 2000 when we they are normally 800 and 1200

Slow Release Drugs Metformin XR 1000mg i tab orally morning The red Tick if Slow Release box is a prompt to prescribers to consider whether or not the standard release form of the drug is required Good practice to also write out the SR, MR, XR, CD 7/1 Metformin XR 08:00 PO 1000mg mane T2DM T.Smith 154 The box must be ticked to indicate a sustained, modified or controlled release form of an oral drug. If it not ticked it is assumed that the standard release form is to be given

Regular Medication orders Benzylpenicillin 1.2g IV every 6 hours Benzylpenicillin 7/1 06:00 12:00 24:00 18:00 IV 1.2 gram 6 hrly pneumonia T Smith 154 Medicine – to be done in generic name. With the exception of combination products – Targin, Seretide, coveram. Be cautious that some combination products (i.e. relatively new ones) aren’t stocked by the hospital – and you may be asked to write them out individually. If you do prescribe in brand name – make sure you know what is in it. Occasionally you see duplicates of orders – Somac vs Pantoprazole Route – avoid dangerous abbreviations – SC vs subcut Dose – to be written out avoid using dangerous abbreviations microg and units Frequency – avoid dangerous abbreviations OD/QD for daily - D Indication – ideally to be written - Prescriber sign & print name – contact details Timing it is the doctors resposnisbility to fill in the timing of the doses – not the nurses – sometimes the nurse fills it in and misses the times. Writing only 8am for bd doses, or specific timing required. Diuretics bd – writing it up at 800 and 2000 when we they are normally 800 and 1200

Variable Dose O once daily For drugs that require drug concentration monitoring document the following for each day of therapy Drug level result Time drug level taken 10/1 15 7/1 8/1 9/1 7/01 Prednisolone For each dose the prescriber must document: Dose Prescriber initials Time to be given 30mg 30mg 25mg 25mg O once daily Pneumonia 0800 0800 0800 0800 T.Smith 154

PRN medication order Paracetamol 500mg ii tabs every 6 hours prn O 1g 6 hrly 4g Pain T.Smith 154 Charting an as required ‘PRN’ medication order Ensure all patient id sections are complete Remember an incomplete order is invalid so ensure you document all of the follwoign Date Generic name (active ingredient name) Route Dose Maximum dose in 24 hours Hourly frequency Indication Prescriber signature and print name The prescriber must check the rest of the chart to ensure that the maximum prn dose, combined with other orders does not exeed the safety limit for the patient The prescriber must write the dose and hourly frequency. “PRN” alone is not sufficient as there is a risk of overdosing and the drug being administered at inappropriate intervals (if the patient is continuously in pain). The indication must be charted so the staff known when it is appropriate to administer that particular drug to the patient The frequency should document the intervals between doses rather than the number of doses per day ( e.g. 6 hrly not 4 times a day)

Changing/Ceasing orders 7/1 benzylpenicillin IV 1.2 grams every 6 hours pneumonia J. Hibbert 154 06:00 12:00 24:00 18:00 1.8 grams NOT ONE order wAS Ceased/changed correctly

Changing/Ceasing orders 7/1 benzylpenicillin IV 1.2 grams every 6 hours pneumonia T.Smith 154 06:00 12:00 24:00 18:00 increased dose 8/1/16 J.Vu 8/1 benzylpenicillin 06:00 12:00 24:00 18:00 IV 1.8 grams every 6 hours pneumonia J.Vu 200 Ceasing and order the prescriber must: Draw a clear line through both the prescription and the administration record sections, taking care that the line does not impinge on other orders – only charting a line from the administration order sometimes leads to drugs being charted up for discharge Write the date the order is to be ceased Write the reason for changing the order (increased dose, written in error or ceased) at an appropriate place in the administration record cessation Included a not to see new order 9if there is one) Sign or initial the ceased order (so we know who ceased it) Do not alter the original order as it is important to know when the change was made to monitor the impact of the change and identify who made the changed. Always cease the original order first before writing a new order (avoids duplicates)

Other examples Intermittent Orders 7/1 Thyroxine X X X X O 100microg alt days 0730 Hypothyroidism Empty stomach , ½ hr before breakfast T.Smith 154 When a drug is not administer daily, the prescriber must clearly indicate this on the chart by using crosses to block out the days that the drug is not to be given

Warfarin Prescribing For each day of therapy document: INR result (if ordered) Warfarin dose Prescriber’s initials 2.3 7 14/01 Warfarin is an anticoagulant ( and a high risk drug) the Warfarin section is printed in read as an extra alert Because of the well-documented risk associated with the use of warfarin, all patients should receive counselling about the use of warfarin and be given written information on warfarin (warfarin book) This section is included as a record that these risk mitigation activities have been completed Completion of this drug order will vary slightly from the Regular Medication order in these ways Warfarin brand must be circled as the two brands are not interchangeable The target INR should be included when warfarin is initially ordered A standard dose time of 1600hours (4pm) is recommended as this allows the medical team caring of the patient to order the next dose based on INR results rather than leaving for after-hours staff to do it 2 – 3 O Atrial fibrilation T.Smith 154

Once only and Nurse initiated medicine orders The Once Only, Pre-medication, Telephone Orders and Nurse initiated Medicine sections are found on the front page of the drug chart. These orders are separate from regular medications so as to reduce the risk of continued administration.