Transcript Prescribing Triangle

All About Prescribing
Workshop
Prescribing in Practice
Part 1
Learning Objectives
• To understand the principles of good
prescribing
• To be aware of the legal requirements of a
prescription
• To be aware of good standards of practice
• To be aware of the importance of
preventing fraud
• To discuss how they prospective
prescriber feels about prescribing
Facts
• More nurses have been sent on nurse
prescribing courses than are currently
prescribing
• Latter et al (2010) found that 93% of nurse
prescribers & 80% of pharmacy prescribers
were using their Independent Prescribing
qualification.
• Evidence suggests that acceptability of NMPs
is acceptability to patients is high and viewed
positively by other HCPs (Latter et al, 2010).
Prescribing errors
• Those occurring in the decision making
process e.g. wrong drug, dose, strength
• Those occurring during the prescription
writing process e.g. illegible prescriptions,
inaccurate transcriptions or poor
communication
• Hospital prescribing errors occur in the range
of 0.56 to 9.9% of all prescriptions Dean et al
(2002) and community 4.35 to 10.2%
Why do errors occur?
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Unintentional slips,
Omissions
Illegible prescriptions
Inaccurate transcription
Positioning of zero and decimal points
causing tenfold errors
• DISTRACTION
Dean (2002) showed that doctors did not
regard the task of prescribing as important.
Computer generated prescriptions
• All prescriptions include drug name, dose,
frequency due to prompts
• Legible
• Information about patient is there at time of
prescribing
• Information about the drug is there as well
• Prescriptions are checked for drug
interactions, and cautions
• Great for audit/pharmacovigilance
• Relevant prescribing details can be built into
system
Feelings
• How do you feel about the prospect
of prescribing?
• How will prescribing benefit your
practice?
• What difficulties/conflicts might you
encounter?
The Law
• The Medicines Act 1968 assures the
quality safety and efficacy of medicines as
well as maintain the safety of the public by
controlling routes of access
• The Misuse of Drugs Act 1971 adds an
additional layer of tougher supply controls
for drugs with a high potential of abuse
Licensing
Why is this important?
• Greater control and safety needed
• Marketing Authorisation (MA) (formerly
Product Licence) granted by MHRA once
they are satisfied of the safety, quality and
efficacy of a drug.
• This process may take many years
• The drug is then licensed
• The MA states the indications and contra
indications & age range for the drugs use
Off Label / Off Licence
• You as a prescriber must be very aware of
the licence situation of all that you
prescribe, because you are liable (or your
employer is) if harm is proven following an
off label prescription
• Such prescribing is common in
paediatrics, palliative care
• Is there anything in your practice that you
will be prescribing off label?
Categories of medicines under Medicines
Act (1968)
Category
General sales list (GSL)
Restrictions on availability
Paracetamol 500mg tabs (16)
They must be sold in original
package, there may be limits on
pack size and must be sold from
permanent premises e.g. garage
Pharmacy medicines (P)
Can only be sold from a registered
pharmacy under the supervision of
a pharmacist who can refuse the
sale
Paracetamol 500mg tabs (32)
Prescription only medicine
(POM)
Paracetamol 1g qds 100 tabs
Can only be supplied or
authorised for supply by an
appropriate practitioner
Controlled Drugs
• Misuse of Drugs Act 1971 aims to prevent the
misuse of drugs that are ‘dangerous and harmful’
• They are grouped in Schedules 1-5
• 1 no medicinal use ecstasy, LSD
• 2 around 100 substances mainly opiates
• 3 barbiturates, temazepam, buprenorphine
• 4 split into benzodiazepines and anabolic/growth
hormones
• 5 preparations of certain CDs pholcodeine,
codeine
Controlled drugs (CDs)
• Nurse / midwife independent prescriber are
restricted to prescribe only certain CDs solely for
specific medical conditions if this falls within their
scope of practice
• A nurse/midwife or Allied Health Professional
supplementary prescriber can prescribe any
schedule 2-5 CD for any condition within their
competence as part of a patient specific, written
clinical management plan agreed with the Dr &
the patient
Controlled Drugs
See Department of Health, Nurse Prescribing
Frequently Asked Questions www.dh.org.uk
(accessed 3/8/11)
Facilitator’s note: ensure up to date list of
Controlled Drugs is used see www.dh.org.uk or
Home Office website www. homeoffice.gov.uk
Controlled Drugs Legislation- Nurse prescribing
and patient group directions for details
Appropriate Practitioners
Originally there were only three
• A doctor
• A dentist
• A vet
Since non medical prescribing more have been added
• A community nurse practitioner
• A nurse independent practitioner
• A pharmacist & optometrist independent practitioner
• A supplementary prescriber (nurses, physiotherapists,
podiatrists, radiographers)
NHS Regulations (see MHRA)
• Blacklist-a list of substances that are not to be prescribed
under NHS pharmaceutical services. If one is prescribed
and the pharmacist dispenses it he will not be reimbursed
e.g. Otrivine nasal spray
• Borderline substances-substances that the NHS consider
to be less suitable for prescribing and will only pay for if the
Advisory Committee on borderline substances approves
that they are regarded as drugs e.g. specialised enteral
feeds or supplements
• Black triangle-a newly licensed drug that is being
intensively monitored ADR reporting important e.g.
fluticasone furoate nasal spray
Who can prescribe what?
‘Independent prescribing is prescribing by a
practitioner responsible and accountable for
the assessment of patients with diagnosed or
undiagnosed conditions and for decisions
about the clinical management required,
including prescribing’
(DH 2006)
Limitations
• May not prescribe blacklisted drugs
• May only prescribe CDs in certain
circumstances
Legislation on prescriptions
• To be legally valid, prescriptions must
comply with regulations made under the
Medicines Act.
• If an invalid prescription is filled the
pharmacist has committed a criminal
offence
Prescription Writing
Legal Requirements
Good Practice
• Your professional body standards on
prescribing/codes of conduct
• Local guidelines
• BNF guidelines
• DH guidelines
Legal requirements
• Name and address of patient
• Signature in ink by the prescriber
• The practice address/address of
prescriber
• The date it was written or date intended
• Information on who the prescriber is (Dr,
dentist, IP, SP)
• The age of the patient if under 12 years of
age
• There are additional requirements for
Validity
• Valid for 6 months from the date of
prescription
• Prescriptions for CDs in schedule 2 & 3
are valid for 13 weeks/28 days
Good Clinical Practice
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Written legibly
DOB included
Dosage instructions clear
Frequency
Formulation
Quantity
The route (N.B.)
Must dos
See BNF for legal and good practice in
prescription writing
BNF gives you very clear directions to be
followed
Can do
• Cautionary and advisory labels…last page
of BNF
– Label 29 & 30…’Do not take more than 2 at a
time and more than 8 in 24 hours’, ‘Do not
take with any other paracetamol products’
Accountability
• Vicarious liability
• Professional accountability
Responsibility
• The practitioner can only prescribe for a patient who
they have assessed.
• Community practitioners may only prescribe on her
own personal prescription pad.
• In the absence of the patient’s original assessor who
has initiated the first prescription the community
nurse may write a repeat prescription or order
repeat doses in order to preserve continuity of care.
• All prescribers have a responsibility to report suspected
adverse drug reactions
ADRs
• Only prescribe when there is a need to prescribe
• If patient is pregnant or breast feeding only prescribe if
absolutely necessary
• Always establish if the patient has allergies or previous
reactions to medications
• Establish if the patient is taking any other medications
• Consider age, renal and hepatic function
• Prescribe as few drugs as possible and start low and go
slow if appropriate
• Only prescribe drugs you are familiar with
• Inform the patient of potential reactions
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Record Keeping (e.g. NMC,
2010)
Accurate
Legible (handwriting)
Unambiguous
Contemporaneous
Relevant
Sufficient
Dated, timed and signed
Signature printed alongside signature
Date prescription written
Name & profession of prescriber & if IP/SP
Name of drug, dose, route, formulation, duration
(See Principle 7
NMC 2010)
Record Keeping
• The record of the prescription should be entered into
the nursing notes and medical records at the time of
writing the script or as soon as practically possible
thereafter at the very latest within 48 hours or by
local arrangement.
(Standards as in NMC (2010) Record Keeping
Guidelines apply)
• Sometimes it might be necessary to inform another
member of the team that a prescription has been
issued. In this case that action should be recorded
in the nursing notes.
Family and Friends
As a non medical prescriber are you
allowed to prescribe for family and
friends?
Blood and Blood Products
• As an IP can you prescribe Blood?
• Blood, packed cells and platelets cannot
be prescribed by an IP as they are not
considered to be a medicinal product and
are so outside the gambit of the Medicines
Act (1968)
• What about derived blood products such
as clotting factors, antibodies and
albumin?
• These are considered medicinal products
Fraud
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Keep secure
Treat like cheques and NEVER pre sign
Extra care in community
NHSBSA recommendations
– Should not be left unattended at reception
desks
– Should not be left visible in a car
– When not in use they should be in a locked
drawer within the surgery & at home
Prescribing in practice
• Visualise how you will prescribe for the
patients in your area, this will help you
integrate skills and knowledge
• This forward thinking will help prepare you
for when your practice begins
• Are there any logistical problems that you
anticipate?
Practical
• Write a couple of prescriptions for drugs
that you will be writing in practice.
• Swap them with your neighbour and go
through the checklist to see if they are
correct
Check List
 Clearly written in ink
 Name and address of
patient
 NHS Number
 Date of Birth
 Age if under 12 years
 Name of drug
 Amount of drug in
correct units
 Route of administration
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Frequency of administration
Quantity to supply
Number of days treatment
Signed and dated
As required drugs should have
minimum dosing interval
 Only use abbreviations listed
 Check dose etc appropriate in
BNF
Summary
• Before you prescribe it is important to
consider the prescribing triangle and
principles of good prescribing
• Refer to BNF and NMC standards for legal
requirements
• Be aware of potential for fraud
Security of prescriptions
• Is the responsibility of the employing
organisation and the prescriber
• Hold only minimal stocks of pads in order
to minimise the impact in case of loss or
theft
• This also helps when forms are reviewed
annually to avoid waste
Serial numbers and loss of pads
• Should be recorded by the employer before issue to the
nurse
• Recorded by the nurse to aid identification in case of theft
• Astron should be contacted if there is loss, or ordered pads
do not arrive
• NHBSA notified if they are not found
• Inform prescribing lead who will contact counter fraud
specialist at the PCT
• They will alert pharmacists and the prescriber will use a
different coloured pad until the matter is resolved
Getting your prescriptions
• After completing the course and qualifying as a IP/SP
Prescriber the NMC/HPC/RPSGB will be informed by
the university and will then annotate the register to
indicate that the NMP can prescribe as either an IP/SP
or SP using the BNF.
( This is different from the HV/DN annotation V100)
• The University will also inform the prescribing leads
of successful course completion.
• Employers can check professional register to
confirm prescribing status
Getting started
• PRESCRIPTION PADS ARE NOT SENT
OUT AUTOMATICALLY.
• FP10 s need to be ordered from the
supplier (currently ASTRON) Orders
cannot be placed with ASTRON until the
NHSBSA have been notified of the new
nurse prescribers details.
• ASTRON will not issue prescriptions
unless the NHSBSA details match those
given by the organisation requesting
Action for employers
• The employer (PCT Prescribing Lead) will
then inform the NHS Business Services
Authority (NHSBSA) of the Nurse/AHP
Prescribers details using the proforma
available on the NHSBSA website:
http://www.nhsbsa.nhs.uk/
(Note hospital based nurses/AHPs do not
need to inform the NHSBSA)
Stock items
 Items should be prescribed for individual
patient use
 Over prescribing to stock up the nurses
own supplies is illegal.
Security of Prescriptions
• The security of Prescription forms is the
responsibility of the Employing
Organisation and the Nurse Prescriber.
• It is advisable to only hold minimal stocks
of prescription forms in order to minimise
loss in the case of theft or break in, and
also helps keep prescription forms up to
date. (normally reviewed annually)
Serial Numbers
• Should be recorded by the employer
before issue to the nurse.
• Recorded by the nurse to aid identification
in the case of theft.
• Blank prescriptions should NEVER be presigned.
Loss of prescription pads
• ASTRON should be contacted about
prescriptions ordered but not received.
• NHSBSA should be notified if they are not
found.
• Community prescribers should inform the
local counter fraud specialist at the PCT,
their manager and the Prescribing Nurse
Lead, if they loose or have prescription
pads stolen.
References cont.
Latter, S, Blenkinsopp, A, Smith, A, Chapman, S, Tinelli, M, Gerard, K,
Little, P, Celino, N, Granby T, Nicolls, P and Dorer G (2010)
Evaluation of Nurse and Pharmcist Independent Prescribing
University of Southampton and Keele University available at
http://eprints.soton.ac.uk/184777/3/ENPIPfullreport.pdf
Medicines and Health care products regulatory agency ww.mhra.gov.uk
Misuse of Drugs Act 1971 www.legislation.gov.uk
Midwifery Council (NMC) (2010) Record Keeping guidelines
www.nmc.org.uk
NHS Business Services Authority www.nhsbsa.nhs.uk
The Medicines Act 1968 www.legislation.gov.uk
References
British National Formulary (BNF) www.bnf.org.uk
Cavell GE, and Hughes DK (1997) Does computerised prescribing improve
the accuracy of drug administration? Pharmaceutical Journal vol 259,
pp782-84
Dean, BS, Schachter M, Vincent, C and Barber ND (2002) Prescribing errors
hospital inpatients: their incidence and clinical significance, Quality and Safety
in Healthcare December vol 11(4) pp 340-44
Department of Health (DH) (2006) Nurse Independent Prescribing
www.dh.org.uk
Department of Health (DH) (2011) Nurse Prescribing Frequently Asked
Questions www.dh.org.uk (accessed 3/8/11
Further reading
Medicinal products: prescription by nurse
and others Act 1992 www.legislation.go.uk
Useful websites
Royal Pharmaceutical Society of Great
Britain (RPSGB) www.rpharms.com
Health Professions Council (HPC) www.hpcuk.org
This work was produced as part of the TIGER project and funded by JISC and
the HEA in 2011. For further information see:
http://www.northampton.ac.uk/tiger.
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