Transcript Document

Rational Drug
Prescription
Introduction to Primary Care:
a course of the Center of Post Graduate Studies In FM
Rabwa Postgraduate Center
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
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How to Prescribe Safely
Clare Hughes
Teacher Practitioner Pharmacist
Aims of talk….
• Evaluate the need to reduce risk from
prescribing medicines
• Discuss the importance of safe prescribing
• Identify ways of improving prescribing
• Describe the NHS plan and the role of the
NPSA
• Identify sources of information which will
help you prescribe safely
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What’s this got to do with you ?
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You will be responsible for prescribing
You will make prescribing errors
You need to be aware of potential pitfalls
You need to think about prescribing safely
You need to know when to ask for help
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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’
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Incidence of errors
• The 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
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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
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Examples….
• Insulin written 7☉ stat given – 70 units
given instead of 7 units
• Erythromycin 500mg iv prescribed in
50ml– vein necrosis should be in 250500ml
• ISMN mistaken for ISTIN
• Vancomycin IV bolus rather than infusion –
cardiac arrest
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• Digoxin 125mg IV not micrograms – cardiac
arrest
• Double rate of aminophylline infusion given –
vomiting
• Weight related clexane – 80kg estimates – pt
weighed 51kg
• Levothyroxine missed on admission –
discovered day 10
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Case 1 – ‘Cambridge’
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Rx Methotrexate 17.5mg once a week
New Rx 10mg once a day
10mg daily dispensed by locum pharmacist
Rx error noticed by 2nd GP, comp. record
unaltered
• +5/7 patient admitted to ENT ward
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• Drug chart written for 100mg daily
• +1/7 Nurse d/w patient – back to 10mg od
• +1/7 Pharmacist queries and asks nurse to
ask Dr to check dose
• GP records confirm 10mg od
• +2/7 blood tests re-checked } Haem
• +5/7 patient dies
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Case 2 – ‘Nottingham’
• Rx Intrathecal methotrexate under GA in
theatre by Oncology Reg & intravenous
vincristine on ward by specialist nurse
• "Outlied" on non-specialist ward
• Both drugs delivered to theatre from
ward
• Given food pre-op, postponed
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• Orignal SpR off-duty now
• Cover SpR unable to leave ward, anaesthetist
to admin intrathecal drug
• anaesthetist given I/Thecal but never given
chemotherapy
• Methotrexate given intravenously
• Vincristine given intrathecally
• Patient died
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Commonest causes of medication
errors
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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
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Legal aspects
• Prescribing covered by Medicines
Act 1968
• Increasing range of prescribers
• If prescribed as per SPC,
manufacturer holds liability
• Medicines without a marketing
authorisation
• Medicines prescribed off label
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An organisation with a memory
(NHS)
400 deaths/yr – medical devices
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10,000 serious ADRs / year
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28,000 written complaints/yr
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NHS spends £400M a year on clinical negligence claims
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Hospital acquired infection costs £1Bn a year (15% may
be avoidable)
THESE DO NOT GIVE THE TRUE SCALE OF THE
PROBLEMS
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Department of Health 1999
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NHS Goals
• Reduce to zero the number of patients dying
or paralysed by maladministered spinal
injections by end 2001
• Reduce by 40% the number of serious
errors in the use of prescribed medicines
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National Patient Safety Agency
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Collect and analyse information on adverse events
Assimilate other safety-related information
Learn lessons and ensure that they are fed back
into practice
Where risks are identified, produce solutions to
prevent harm, specify national goals and establish
mechanisms to track progress
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Prescribing responsibilities
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Drug
Dose
Route
Frequency
Rate of administration
Duration of treatment
Allergies and
sensitivities
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• Provide a prescription that is
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LEGIBLE (!!!!!)
Legal
Signed
Giving ALL
information to allow
safe administration
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Controlled drugs
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Drug history taking
• Current medication
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Dose
Form
Strength
Frequency
Indication
• Past medication and Tx failures
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Over the counter medication
Recreational drugs
Adverse reactions
Allergies and sensitivities
What was the allergy
Estimate of compliance
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Information Sources
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GP letter – may be inaccurate / incomplete
Printed GP letter – may not be up to date
Patients own tablets
Written lists
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Common pitfalls
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No direction on label
Not brought any of own tablets in
No / unclear strengths eg inhalers
Trade names – beware duplicates
Patient can’t remember
GP records out of date
Dosette boxes – tablet ID
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Safe prescribing
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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 (0.5ml NOT .5ml)
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• 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)
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Take extra care if:
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Impaired renal function
Hepatic dysfunction
Children
The elderly
Drug unknown to you
Very new drug
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How can we help you ??
Clinical Pharmacists
• View charts daily
• Check doses etc
• Check interaction
• Check appropriateness
• Provide advice and
information
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Medicines Information
• All hospitals have
• At end of phone
• Answer all queries
large or small
• There to help you
prescribe safely
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Prescribing guidelines and
resources
• Developed to
standardise treatment
• Evidence based use of
medicines
• Try and familiarise
yourself with these
• Often now on intranets
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Summary
• Provide a clear, unambiguous and legal
prescription
• When in doubt - ASK
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Prescribing Quiz
• Teams of 4/5 people
• If need additional
information write
‘need info on . . .’
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Question 1
A frail 80 year old lady is admitted with falls, a
chest infection and feeling sick. PMH – AF and Hypertension
The medication history is recorded as:
Bendroflumethazide 5mg daily
Atenolol 50mg daily
Ramipril 1.25mg daily
Aspirin 75mg daily
Warfarin 3mg daily
Digoxin 250 micrograms daily
She was started on Benzylpenicillin IV 2.4G qds and
Ciprofloxacin po 400mg bd
List 5 potential problems with this prescription….
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Question 2
A patient has come in with RTI and has the
following on the drug chart.
Benzylpenicillin 2.4G IV qds
Ciprofloxacin 750mg bd
The patient has had the antibiotics for 2 days is
better and ready for discharge – write a TTO
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Question 3
A patient is admitted on-call via GP. The GP letter
states that the patient is currently receiving:
ISMN 60mg / day
Nifedipine 30mg /day
Atorvastatin 30mg / day
Fill in the ‘in-patient’ drug chart for this patient
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Question 4
NHS goal – how much do the number of
serious errors in the use of prescribed
medicines need to reduce by ?
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Question 5
Give the generic names of the following
• Zocor
• Tegretol
• Istin
• Losec
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Question 6
A patient is going home and needs the
following:
MST 30mg bd for 14 days
Please write the prescription (excluding
name and address)
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Question 7
A patient needs Vancomycin 500mg bd IV
Write up in patient drug chart
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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
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Question 1
A frail 80 year old lady is admitted with falls, a
chest infection and feeling sick. PMH – AF and Hypertension
The medication history is recorded as:
Bendroflumethazide 5mg daily
Atenolol 50mg daily
Ramipril 1.25mg daily
Aspirin 75mg daily
Warfarin 3mg daily
Digoxin 250 micrograms daily
Dose for HTN 2.5mg
?causes of falls
Dose of ciprofloxacin – 750mg bd
Aspirin and warfarin interaction
Warfarin and antibiotic interactions
Dose of digoxin too high
She was started on Benzylpenicillin IV 2.4G qds and
Ciprofloxacin po 400mg bd
List 5 potential problems with this prescription….
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Question 2
• Amoxycillin 500mg tds for 5 days
• Ciprofloxacin 750mg bd for 5 days
• -1 if unsigned
• Max 2 marks
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Question 3
• Isosorbide mononitrate MR 60mg
prescribed at 8am
• Nifedipine 30mg MR prescribed daily
• Atorvastatin 30mg prescribed at night
• -1 mark if no signatures included
• -1 mark if no routes included
Max 3 marks
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Question 4
40%
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Question 5
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Zocor = simvastatin
Tegretol = carbamazepine
Istin = amlodipine
Losec = omeprazole
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Question 6
Morphine (Sulphate) MR (SR) tablets 30mg
BD (for 14 days)
28 (twenty eight) x 30mg
(840mg – eight hundred and forty milligrams)
Signed dated and print name
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Question 7
Drug
8
x
Vancomycin
Dose
Route
500mg
IV
Signature
Start Date
Pharm
Stop Date
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18
x
Squiggle
Additional instructions
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In 100mls NaCl 0.9% over 60 mins
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Question 8
• Amiodarone 200mg tds for 4 days then bd
for 7 days then daily
• Simvastatin 10mg on
• Frusemide 40mg bd for <7 days then to be
reviewed by GP
- will accept 40mg om as dose change
- No zopiclone required as started in hospital
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