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Prescribing Safely Kevin Gibbs Pharmacy Manager: Clinical Services

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1 Prescribing Safely Kevin Gibbs Pharmacy Manager: Clinical Services
University Hospitals Bristol NHS Foundation Trust


3 Aims of talk…. Discuss the pitfalls of drug history taking
Introduce medicines reconciliation Help you to reduce risk from prescribing medicines Identify sources of information which will help you prescribe safely Revision from 3rd year talk! Give you pointers to ask on your placements

4 Why me? You will do this every day
You will be responsible for your prescribing You will make prescribing errors You will be expected to prescribe to NPSA competencies (Eg Anticoagulant & IVs) You need to be aware of potential pitfalls You need to think about prescribing safely You need to know when to ask for help

5 What is a medication error ?
‘ a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer’ Errors can occur in prescribing dispensing administration counselling

6 Incidence of errors The precise incidence of medication errors in the NHS is unknown ~10-20% of all ADRs are due to errors In USA 1.8% of hospital admissions have a harmful error leading to 7000 deaths per year In Australia – 1% of all admissions suffer an ADR due to medication error

7 Common error types? Wrong patient Contra-indicted medicine
Wrong drug / ingredient Wrong dose / freqency Wrong formulation Wrong route of administration Poor handwriting on Rx Incorrect IV administration calculations or pump rates Poor record keeping Paediatric doses Poor administration techniques

8 TL Granisetron 1mg po od x 5/7
Temodal ( Domperidone Movicol TR Granisetron 1mg Dexamethasone 8mg BL NaCl (Sodium Chloride 0.9%) 1 litre 1 hour 5% dextrose 250ml 2 hour + ?? I think!!

9 Most common types of medication error reported

10 Commonest causes of medication errors
Lack of knowledge of the drug – 29% Lack of knowledge about the patient – 18% “rule” violations – 10% “Slip” or memory loss – 9% JAMA 1995;274:35-43

11 Top Therapeutic Groups Reported

12 Prescribing responsibilities
Drug Dose Route Frequency For parenteral therapy Diluent and infusion volume Access line for adminsitration Rate of administration Duration of treatment Allergies and sensitivities

13 Provide a prescription that is
LEGIBLE (!!!!!) Legal Signed Giving ALL information to allow safe administration

14 Controlled drugs In your handwriting: Name and address of patient
Drug and dose Form and strength of the drug Modified release Strength if liquids/injections Total quantity (or no. of dosage units) in WORDS and figures) The requirements for a hospital take-home prescription are the same

15 Drug history taking What information should be gathered during a drug history? What is the aim of the drug history? Where do you find the information? What is “Medicines Reconciliation”?

16 Drug Histories: What information?
Current medication Dose Form Strength Frequency Indication Past medication and treatment failures

17 Over the counter medication
“Recreational” drugs Adverse reactions Allergies and sensitivities - with clinical detail Estimate of patient adherence / concordance with their medicines

18 DHx: Information Sources
GP admission letter GP records – From surgery / fax Patients own tablets “Dosetts” = Multi-compartment compliance aids Written lists – Patient / carer Nursing home form Pharmacist patient records Recent discharge letters

19 GP admission letter Do not always contain a drug history Out-of-hours
Can only contain those deemed relevant to admission Out-of-hours No information for out-of-hours GP services to call on; so incomplete or reliant on patient’s memory / own medication

20 GP records Should be definitive; but:
May be inaccurate / incomplete if: Recent discharge not reached GP and acted upon Recent discharge had changed medicines with no explanation Some drugs are secondary-care only or issued in specialist units eg post-transplantation / specialist clinics (CF, psychiatric etc) These may not be on the GP record The doses may be altered by the originating unit not the GP, so GP records may not be accurate

21 GP records - 2 Private prescriptions may not be recorded on GP computer Watch the date last issued Has this been stopped? Is the patient no longer taking the medicine Adverse reaction? Lack of effect? Will have allergies and sensitvities


23 Patient’s own medicines
Are these for the correct patient? Easy to pick up a relative’s medicines by mistake Easy to miss if the same surname Are they still taking these? Stopped without GP being aware Stopped with GP agreement but still on GP list Stopped a while ago but kept “just in case” Contents of medicine cupboard emptied! Compliance aid boxes have lists inside

24 Previous drug chart or discharge letter
How current are these? More recent changes? Check with the patient Incidences of errors with typist-generated letters Co-careldopa 3.125mg tds – Prescribed on next admission Was tds Electronic discharge summaries Errors from picking incorrect drop-down list

25 Nursing Home list MARs sheet Similar to a hospital drug chart
Medication Administration Record Similar to a hospital drug chart Should be an accurate list

26 Community pharmacist records
If one pharmacy is used regularly this can be a additional source of information Open on saturdays Will include all prescriptions dispensed fo that patient including But may also miss hospital-only medicines

27 Top 10 drug groups most commonly associated with preventable drug-related admissions
All preventable drug-related admissions (%) ADRs and over treatment (%) Patient adherence problems (%) Under treatment (%) Antiplatelets 16.0 17.3 2.0 8.9 Diuretics 15.9 20.4 2.2 NSAIDs 11.0 12.0 4.1 Opioids 8.5 Beta-blockers 4.6 4.4 11.1 Drugs affecting renin –angiotensin system Drugs used in diabetes 3.5 3.2 9.2 Positive inotropes 3.1 Corticosteroids Antidepressants 3.0 Howard et al Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol 2006;63(2):

28 Other common pitfalls Prescribed & labelled ‘As directed’
Own tablets not brought in Several possible strengths eg inhalers Trade names – beware duplicates Patient can’t remember “Dosett” boxes X tablet identification Asking about “your tablets” – Patients will then miss off inhalers, creams etc!

29 Take extra care if: Impaired renal function Hepatic dysfunction
Children The elderly Drug is unknown to you Very new drug

30 Medicines Reconciliation: Definition
“Collecting an accurate list of the patient's home medicines, using that list to write prescriptions; and documenting changes or discontinuation of medicines and doses” National Guidance National Institute for Health and Clinical Excellence: Patient Safety Guidance 1. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. <>

31 Medicines Reconciliation: Process
Verification: Collection of the medication history Obtaining a complete and accurate list of each patient's current medications (medication history) including name, dosage, frequency and route Clarification: Ensuring that the medications and doses are appropriate Comparing the in-patient prescription or TTA to the medication history Reconciliation: Documentation of changes in the prescriptions Resolving any discrepancies that may exist between the medication history list and prescribed medicines before an adverse drug event (ADE) can occur Note: ADEs can result from omitted drugs or doses This is done at admission, on transfer between levels of care, on discharge

32 If we don’t reconcile medication?
Systematic review showed 30-70% for unintentional variances between the medication patients are taking and their subsequent in-patient prescriptions1 Examples Omeprazole started in ITU for prevention of stress ulceration. No GI Hx. Carried on for 3 years Admitted for surgery. PMH: RA, HTN GP history not used Not given regular meds for 6 days Prednisolone 5mg, Methotrerxate, Alendronic acid, ramipril, Bendroflumethiazide, Alendronic acid, Folic Acid Painful joints, stiffness, BP 1: Campbell etal. A systematic review of the effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission. University of Sheffield School of Health and Related Research. September 2007

33 If we don’t give the GP full details?
How will she know what we have done? What we have stopped and why What we have started and why What they should look out for or monitor, Tx goals Their records will not be up-to-date Patients are confused Different lists from hospital and the GP Medication is stopped by GP as no idea why started There will be errors on the next admission

34 Minimum information to be supplied at discharge
Complete and accurate patient details (full name, date of birth, weight if under 16 years, NHS number, consultant, ward discharged from, date of admission, date of discharge) The diagnosis of the presenting condition plus co-morbidities Procedures carried out A list of all the medicines prescribed for the patient on discharge (and not just those dispensed at the time of discharge which are in addition to the regular medication) Dose, frequency, formulation and route of all the medicines listed Medicines stopped and started, with reasons Lengths of courses where appropriate (e.g. antibiotics, clopidogrel) Details of variable dosage regimens (e.g. oral corticosteroids, warfarin etc) Known allergies, hypersensitivities and previous drug interactions Any additional patient information provided such as corticosteroid record cards, anticoagulant books etc. Further inflromation available at url: <>

35 Safer Prescribing Know your patients Know your medicines
Use a limited number if possible to aid familarisation – Prescribing Formularies Use your resources Peers Pharmacists Specialists (medical & non-medical) Guidelines and decision support help National help National Patient safety Agency – Alerts and reports MHRA – Monthly newsletter for prescribing and adverse reactions Sign-up for this on website

36 Alert 20:Promoting Safer Practice With Injectable Medicines
NPSA receives 800 incident reports a month concerning injectable medicines. 24% of all medication incident reports. 58% of incident reports leading to death and severe harm.


38 Decision-making with pharmacological therapy: ENCoRE
Explore identify patient nature of symptoms other medicines or treatment allergies and ADRs adherence to treatment exclude serious disease No medication option unnecessary contra-indicated Care over older people children pregnancy/lactation Refer potentially serious problems persistent symptoms Explain suggested course of action

39 Pharmacy help View charts daily Check doses, calculations etc
Check interactions Check appropriateness Provide advice and information Help with prudent antibiotic use Medication reviews for patients On admissions units Take medication histories Help with reconciliation

40 Medicines Information Dept.
All hospitals have access to one - phone/bleep Any medicines-related enquiry eg Treatment options Drugs in pregnancy Evidence collection and collation There to help you prescribe safely

41 Prescribing guidelines and resources
Developed to standardise treatment Especially: If evidence is conflicting / high risk / high cost Evidence based use of medicines Find out what is available in your Trust Usually intranet-based BNF / Medusa intravenous drugs guide Policies Medicines codes or policies MUST read and follow

42 Intranet-based BNF – Localised with Formulary/Local text



45 Intranet IV administration Guide “Medusa”

46 clinical features of acute hyperkalaemia
hyperkalaemia is defined as a serum potassium greater than 5.2 mmol/L other signs and symptoms (1) usually asymptomatic but can include; tingling paraesthesia muscle weakness flaccid paralysis ECG signs if present treat urgently tall, peaked T-waves, followed by flattening of P-wave, prolongation of PR interval, QRS widening, and development of S-wave, arrhythmias (bradycardia, VT, VF) deterioration to asystole at a serum potassium around 7mmol/L or more potential precipitant causes i initial management i

47 Prescribing Quiz Teams of 4/5 people
If need additional information write ‘need info on . . .’

48 Question 1 A frail 80 year old lady is admitted with falls, a chest infection and feeling sick. PMH AF and Hypertension DHx Bendroflumethazide 5mg daily Atenolol 50mg daily Ramipril 1.25mg daily Aspirin 75mg daily Warfarin 3mg daily Digoxin 250 micrograms daily O/A Benzylpenicillin IV 2.4g qds and Ciprofloxacin po 400mg bd List 5 potential problems or issues with this prescription….

49 Question 2 Benzylpenicillin 2.4G IV qds Ciprofloxacin 750mg bd
Drug chart = Benzylpenicillin 2.4G IV qds Ciprofloxacin 750mg bd After 2 days therapy the patient can be discharged – write the take home prescription (TTO – To Take Home) (TTA – To Take Away)

50 Question 3 ISMN 60mg / day Nifedipine 30mg /day
A patient is admitted on-call via GP cover service. The admissions letter states the medicines as: ISMN 60mg / day Nifedipine 30mg /day Atorvastatin 30mg / day Fill in the ‘in-patient’ drug chart for this patient

51 Question 4 2001 NHS goal – By how much did the number of serious errors in the use of prescribed medicines need to reduced by 2005?

52 Question 5 Give the generic names of the following Zocor Tegretol
Istin Losec

53 Question 6 A patient is going home and needs the following:
MST 40mg bd for 14 days Please write the prescription (excluding name and address)

54 Question 7 A patient needs Vancomycin 500mg bd IV
Write up in patient drug chart

55 Question 8 Patient is due to go home and has the
following on in patient Rx: Amiodarone 200mg tds (started 4 days ago) Simvastatin 10mg on Furosemide 40mg bd (for post-op peripheral oedema) Zopiclone 7.5mg on (started in hospital) Write patients TTO for 1 mth

56 Answer: Question 1 Bendroflumethazide 5mg daily Dose for HTN is 2.5mg
Atenolol 50mg daily ? cause of falls Ramipril 1.25mg daily Seems low, has this been dose-titrated? Aspirin 75mg daily Aspirin and warfarin interaction Warfarin 3mg daily Warfarin and antibiotic interactions Digoxin 250 micrograms daily Dose ? high as elderly – check levels Benzylpenicillin IV 2.4G qds Ciprofloxacin po 400mg bd = IV dose, oral dose is 750mg bd 1 mark per green answer

57 Answer: Question 2 Change IV to oral Amoxycillin 500mg tds for 5 days
Ciprofloxacin 750mg bd for 5 days -1 if unsigned 1 marks each

58 Answer: Question 3 Isosorbide mononitrate MR 60mg prescribed at 8am
Nifedipine 30mg MR prescribed daily Atorvastatin 30mg prescribed at night But an unlikely dose as generally 10mg, 20mg or 40mg (No 30mg tablet) - Check 1 mark each -1 if no signature included -1 mark if no routes included

59 Answer: Question 4 40%

60 Answer: Question 5 Zocor simvastatin Tegretol carbamazepine
Istin amlodipine Losec omeprazole

61 Answer: Question 6 Morphine (Sulphate) MR (SR) 40mg BD (for 14 days)
28 (twenty eight) 30mg MR tablets 28 (twenty eight) 10mg MR tablets (1120mg – one thousand, one hundred and twenty milligrams) Sign, date and print name

62 Answer: Question 7 Vancomycin 500mg IV 6.1.9 Review 10.1.9 x Squiggle
Drug Vancomycin 8 x Dose 500mg Route IV Start Date 6.1.9 Stop Date Review 10.1.9 12 Signature Squiggle Pharm 18 Additional instructions In 100mls Sodium chloride 0.9% over 60 minutes via peripheral line 24

63 Answer: Question 8 Amiodarone 200mg tds for 4 days then bd for 7 days then daily Simvastatin 10mg on Frusemide 40mg bd for a set time Add a note to the GP for review will accept a dose change eg 40mg om No zopiclone should be required as started in hospital

64 Summary: Safe prescribing
Clear and unambiguous Use approved names No abbreviations eg ISMN Unless G or mg then write units in full (micrograms or nanograms) Avoid decimal points – if needed then make very clear: .5ml X 0.5ml  Avoid a trailing zero: 1.0mg X 1mg  Avoid fractions: 0.5mg X 500 micrograms 

65 When in doubt - ASK Rewrite charts regularly
If amend prescription re-write or sign and date amendment For frequency use standard abbreviations eg od / bd / tds etc If using a dose by weight calculate the dose needed (NOT 1.5mg/kg) Take time (e.g. to read patient information) Use your resources When in doubt - ASK

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