Transcript Prescribing for Junior Doctors

Pharmaceutical
Services at DGRI
Mon - Fri 8.30 - 5.00
Sat - Sun 9.00 – 17.00 (Last prescriptions
received in pharmacy by 4pm)
On-call via switchboard for advice or
emergency supplies only
Pharmaceutical Services at DGRI
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Clinical
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Aseptic
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Dispensary
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Medical Information
Clinical Service
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The pharmacist is responsible for ensuring
prescribing is safe, effective, and economical
Clinical pharmacists aim to review new patient
admissions in ward 7/8/ICU daily, but annual
leave and public holiday cover is not provided
so do not assume that we have seen everyone!
See notice in doctors room for pharmacist ward
cover: medical wards call ext 31318
surgical wards call ext 32990
Clinical Service (contd)
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Ward cover varies therefore contact pharmacy if
there is a patient you would like us to review
Happy to answer your questions
Aseptic/Nutrition Service
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Sterile production of all cytotoxics
Nutrition team manage ordering of all TPN
(total parenteral nutrition)
Orders must be in pharmacy by 11am
Ensure you request daily bloods indicating
‘TPN bloods’ on biochemistry form
Caution with concurrent fluids-TPN already
provides maintenance, extra only required if
replacement fluids indicated
Dispensary Service
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Every prescription is clinically checked by a
pharmacist before it can be dispensed, any errors
or queries will hold up the dispensing process
(can take 20 minutes or longer per patient)
We need at least 1 hour to dispense a prescription
after clinical check
4 hours is required for blister pack prescriptions
to be dispensed safely
Check the prioritisation of discharge prescriptions
with your ward team (e.g. morning ambulances or
compliance issues)
Dispensary Service (part 2)
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Patients get frustrated when they are told at 9am
to go home but their prescription is not typed
until 3pm
Manage patient expectation - When you tell
patients they can go home make sure they have a
realistic understanding of how long it will take to
get their medicines ready including you getting
time to write the discharge
No pharmacy staff capacity for prescriptions
received after 4pm to be completed the same
day
Medicines Information Service
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Deal with any enquiry regarding medicine
For inpatients always contact your ward clinical
pharmacist with any medicine enquiry
We answer enquiries from within the hospital as
well as from GPs, district nurses, patients,
community pharmacists etc.
The medicines information phone is not
permanently staffed - answering machine
checked throughout the day
Prescribing
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HEPMA (Hospital Electronic Prescribing and
Medicines Administration System) is being
rolled out across DGRI in 2015/2016
This requires all inpatient medicines to be
prescribed and their administration recorded via
an electronic system.
HEPMA also provides discharge medication
information to the Immediate Discharge Letter.
Prescribing (contd)
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Live throughout DGRI excluding ICU / A&E /
Paediatrics / Obstetrics
Psychiatry and Paediatrics planned Autumn 16
Initial training via LearnPro (or at induction)
No training = No password
ASK if you need help!
HEPMA team on x32410.
Prescribing (contd)
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The majority of prescribing should be generic
Some drugs must always be prescribed by brand
e.g. theophylline, lithium, diltiazem, all antiepileptics see formulary for list
Preparations containing more than one drug
may be prescribed by brand e.g. Rifinah tablets
Indicate if a modified release preparation is
required-omitting this can be clinically
significant eg. Carbamazepine MR
Prescribing (contd)
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Supplementary medicine charts for variable dose
medicines will still require a handwritten chart
e.g. warfarin, insulin, heparin, gentamicin,
vancomycin
A medication chart is essentially an item of
written communication, but it also has legal
importance
You must write clearly so that the nurses can
carry out your instructions without asking for
further clarification
Please write in block capitals, sign, and date
each drug. Always include your phone number
Prescribing Cost Effectively
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Prescribe according to formulary on Hippo and
in doctors handbook
Any requests for non-formulary products must
include reason for request (HEPMA will
enforce) & will be authorised by pharmacy
New medicine process
Assessment – clinical benefit, cost, safety, impact in
primary care
 If non Scottish Medicines Consortium approved or
unlicensed – needs to go to Medical Director/
Exceptional prescribing committee
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Prescribing in Out-patients
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Use blue HBP5 prescription pad
Advise patients that medicine will be dispensed
by a community pharmacy of their choice. We
only dispense for inpatients or if a hospital only
medicine is required
Use the formulary
Generic name (unless clinically appropriate to
use brand)
PRINT contact number and clinic
Prescribe quantity – max 1 month
Patients Own Drugs
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All patients encouraged to bring in PODs, these
are assessed & placed in their wall locker for use
with medicine reconciliation & on medicine
rounds
Any medicines not brought into hospital or
additional drugs will also be placed in the locker
These medicines will either be transferred with the
patient to their next ward or be sent to pharmacy
with the discharge prescription
Medicines Reconciliation
 Med Rec =obtaining the most accurate list of a
patient’s current therapy
 Electronic med rec is being rolled out across the
organisation and is more efficient(see a pharmacist for
more info)
 This will become a significant part of your role as
a hospital doctor, a complex med rec can take up
to 20 minutes to complete
 Med Rec should be carried out on admission, checked
at each ward transfer & discharge.
Medicines Reconciliation
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Use all available resources (minimum of 2)
-ask patient/carers what they are actually
taking.
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Review medications in line with current clinical
condition and document changes
Must be performed for EVERY patient
Accuracy is audited as part of the Scottish
Patient Safety Programme
Medicines Reconciliation
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You must complete the Module on LearnPro
Remember 50% of handwritten GP letters are
inaccurate
Over the counter & hospital only medicines may
not be listed in GP records! You must speak to
your patient/carer
If in doubt contact your clinical pharmacist
Insulin
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High risk drug – common source of errors
Prescribe dose “as charted” on Medication chart
/ HEPMA and refer to insulin chart
Select the correct device - Flexpen, penfill, vial
Variable rate insulin charts contain full guidance
Always write ‘units’ in full, do not abbreviate
Include a note of the current dose being used in
units on discharge prescription
Controlled Drugs
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Legal requirements for discharge prescription as per layout on IDL.
Info in handbook and BNF (both online!)-usually prescribe 7 days worth on discharge
Common errors= the strength, form of preparation and total quantity to supply missing!
Drug/ Form of
preparation
Route of
Dose
Admission
Frequency
Days
Recommended
Fentanyl Patch 50
micrograms/hour
topical
One
every 72
hours
2 (Two)
patches
5mg
over 24
hours sc
7 amps
(seven)
Midazolam Injection Subcutaneous
10mg/2ml
Note if prescribing more than one strength of a medicine-prescribe each strength separately as
example below with morphgesic dose of 50mg BD
Morphgesic
tablets 10mg
Morphgesic tablets
30mg
oral
20mg BD
28 tabs
(twenty eight)
oral
30mg BD
14 tabs
(fourteen)
Steroids
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Always check indication
Check current dose with patient as GP records only
state ‘as directed’ with variable dose regimes
If oral route unavailable switch to IV hydrocortisone
(see handbook for details)
State course length on discharge- if long term then
please state this-risk of addisonian crisis if stopped
Consider tapering down regime if had >3 weeks
treatment
Inhalers/Nebules
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High cost medicines!
Device type-accuhaler, easibreathe, diskhaler,
turbohaler, MDI, easyhaler
Strength-not the number of doses in the device!
Beclometasone-prescribe as brand
QVAR or Clenil Modulite
Does the patient have a home nebuliser?
Do not give ipratropium nebules and tiotropium
inhaler together
Antibiotics
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Antibiotic guidelines are on HIPPO
 Follow them – if deviate document why. They’re all on HEPMA starting
ABX
You will be questioned if you prescribe a restricted antibiotic to check it
has been recommended by infectious disease or microbiology consultant
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Document stop date on HEPMA for all oral antibiotics and after 72 hours
of IV antibiotics document a review plan using a note in HEPMA. IV
antibiotics should be reviewed daily after 72 hours
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Document indication for antibiotic using note in HEPMA it helps ensure
efficient and effective communication
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Gentamicin therapy should not continue longer than 3 days without
discussion with consultant microbiologist to establish risk/benefit and
other treatment options
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If a patient receives gentamicin for longer than 7 days they should be
referred to audiology
Warfarin
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Document dose on medication chart / HEPMA
“as charted” and refer to warfarin chart
Document INR target and indication on
warfarin chart
Check for interactions/liver disease. Watch INR
if starting antibiotics!
All new start patient’s require counselling-refer
to pharmacy
You must organise follow up INR appointment
at discharge
Benzodiazepines
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Review need at discharge
Advised for short term use only
Clozapine
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Always alert pharmacy team -contact on call
pharmacist if you cannot find the dose
Missed doses will be treated as a critical incident
Analgesics/Antiemetics
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See Acute Pain Team protocol
Caution regular & PRN analgesic duplication i.e.
paracetamol and co- codamol
Caution: reduce IV and oral paracetamol dose to
15mg/kg QD if less than 50kg
Only prescribe one opiate at a time i.e. if regular
morphine stop codeine
Tramadol is second line as a step 2 analgesic (also needs
to be prescribed as a controlled drug)
Antiemetics-think pharmacology, check for
contraindications
Allergies can be fatal!
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Errors have occurred
where patients have been
prescribed and given
penicillins despite having
a documented penicillin
allergy.
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Make sure you are not
the unlucky one who
causes a patient to suffer
anaphylaxis.
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Please check allergy
status before prescribing
any medicine. HEPMA
will warn you – read the
warning!
Allergy Status
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Always check allergy status in notes, GP letter,
with patient/ relative. HEPMA may have allergies
from previous admissions– check still accurate.
Must be recorded
in the notes
 on the medicine chart
 on the discharge prescription
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What is the reaction-true allergy?
If a new allergy is discovered, record it.
Emergency Care Summary
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Remember ECS has been found to be only 80% accurate
Watch issued dates-patient may have stopped a medicine
Medicines prescribed at hospital clinics won’t always be recorded
on ECS as this has only recently started happening
Discharge Prescriptions
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Should be done ASAP-traffic light system on
ward boards, liaise with ward charge nurse
Use HEPMA and the electronic immediate
discharge programme
Include ALL the drugs the patient is on
Controlled Drugs- advice in
handbook/Hippo/BNF or ask us if still in
doubt!
If within pharmacy hours – pharmacist verifies
discharge prescription before e-mailing to GP
and printing off patient & casenote copies.
Discharge prescription checklist
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This may take at least 20 minutes – plan your time
Perform medicines reconciliation using medicine chart
& medicines reconciliation form on admission
Speak to patient/pharmacy team if any discrepancies
noticed (you will pick up many errors at this point)
Where are they being discharged to? Transfers to
peripheral hospitals must be stated
Pharmacy copy must be signed including phone no.
Have you given it to nursing staff? Nursing staff alert
pharmacy team
If after 4pm contact ward pharmacist directly as there
may not be capacity for late/unplanned prescriptions
And Finally………...
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we cannot dispense prescriptions for members
of staff - if you need a prescription, get a GP!
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we are here to help you with anything to do with
drugs, prescribing, administration, availability,
compatibility, etc. Please ask for help as we do
not provide a clinical service to all wards.