Prescribing Getting It Right the First Time

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Prescribing (Getting It Right the First Time)
Yolinda Haarhoff Pharmacist Teacher
Practitioner Cambridge Graduate Course for
Medicine (e-mailYolinda.Haarhoff_at_wsh.nhs.uk)
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Objectives

• Importance of Teaching Prescribing
• Why do errors occur?
• Practical prescribing advice
• Different drug charts
• Examples of common errors

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• 25 July 2000
• 113 dead
• Entire world in shock

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Deadly Toll of Medication Errors

• Pilot study in 2 London hospitals
• What is clear is that we need to know more about
  errors and do more about them
  - Sir George, BMJ March 2002

Adverse events in gt1 in 10 pts
1/3 of these are serious
In 8 of these cases, it lead to the patients
death
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To Err Is Human
The Audit Commission A spoonful of sugar -
medicine management in NHS hospitals

• Core cirricula at medical schools do not provide
  a thorough knowledge of safe medicine prescribing
  and administration
• DoH goal for NHS to reduce medication errors by
  40

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To Err Is Human Why Teach Prescribing?

• Errors more likely when new Drs arrive in
  Hospital - Audit Commission a Spoonful of
  sugar
• Continuing education in prescribing technique
  required for new doctors
  - Irish medical Journal

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Medication Errors and Reducing Risk JHO
Prescribing OSCE

• Average achievement 58
• If 70 was required only 5 would pass
• Difficulties
• Drug allergies interactions
• Writing a CD prescription
• Unfamiliar with BNF

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Human Aspects of Errors

• Impedance of Performance
• - Fatigue Sleep deprivation
• - Hunger Long lapses between food/drink
• - Concentration Lapses
• - Stress Loss of control/cutting corners
• - Other factors Alcohol, drugs illness

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Spot the difference?
Look alike drugs contribute to medication errors
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Spot the difference?
Look alike drugs contribute to medication errors
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Spot the difference?
Look alike drugs contribute to medication errors
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• Administering the wrong drug could be fatal
• NHS standard
• Water
• Sodium chloride
• Lignocaine

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Error Prevention

• The Five Rs
• Right Patient
• Right Drug
• Right Dose
• Right Route
• Right Time

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Prescribing Protection
Your Best New Friend!
BNF

• Reference source for prescribing
• If uncertain, look it up - ALWAYS
• Use in conjunction with trusts medication
  policy formulary

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BNF What can it do for me?

• Front section
• Prescribing guidance, prescription writing CD
  prescribing
• Prescribing in children, elderly palliative
  care
• Emergency treatment of poisoning
• Middle section
• Approved Drug Name with indications, S/E,
  cautions dose
• Back section
• Appendixes interaction, pregnancy
• Approved abbreviations (BNF Back page)

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Formularies Essential Drugs

• National formularies (e.g. the BNF) provide an
  independent source of advice
• Hospital formularies reflect hospital choices
• WHO provide a model list of essential drugs
  (300 items) some controversial!
• Personal formularies can be useful

Most prescribing limited to 100 formulations
(vs. gt 60,000 total)
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Legal Aspects Governing Prescribing

• Medicine Act 1968
• Poisons Act 1972
• Misuse of Drugs Act 1971

Regulates ALL retail and wholesale dealings in
medicine
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The Prescription
Should state - what is to be given to whom and
- by whom prescribed, and give instructions
on - how much should be taken how often, - by
what route and for how long or total quantity
supplied
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Controlled Drugs Prescriptions

• Handwritten requirements
• NAME, FORM STRENGTH of drug and dose
  Morphine sulphate SR tablets 10mg 20mgbd
• Methadone liquid 1mg/ml
  10ml od
• TOTAL QUANTITY in WORDS and FIGURES
• 50 (Fifty) tablets
• 20 (twenty) ml
• YOUR Signature and DATE (include bleep no.)
  BNF p7

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Hospital Prescribing

• Includes
• Evaluation of patients current medication
• Selecting medication for treatment - indication,
  formulary, licence agreements, efficacy
• Stating considerations - antibiotics duration
  of treatment
• - warfarin discharge dose next INR date
• Discharge medication (or TTO) not just a
  rehash of the drug chart

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Before Writing a Drug Chart

• ALLERGIES
• COMPLETE Drug History
• what they are taking today and why
• what has been stopped recently
• what they are buying themselves
• OTC, herbal, homeopathic and frequency
• what are they unable to take and why
• HRT oral contraceptives

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Before Writing a Drug Chart

• Sources of information
• GP letter stating current medication
• Patients own drugs
• What have they got with them?
• Can you positively identify each drug?
• Is the dosage correct?
• What state are they in can it be used?
• Can their relatives/carer bring it in?

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Prescription/Drug Charts

• ALLERGIES
• BLOCK CAPITALSApproved name in BNFNOT trade
  name abbreviations
• Dose, frequency, route
• Sign entry with bleep number

If in doubt check, never guess see BNF
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Drug Name Abbreviations

• NO!!! ALWAYS Avoid
• ISMN prescribed, patient got Istin
• BNF

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Prescription/Drug Charts
CYCLIZINE 50mg 7/11 S Jones
PO Nausea 150mg/24h

• PRN criteria
• frequency
• max dose
• indication

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Completing Drug Charts Important points

• Care when rewriting drug charts / transferring
  information to discharge summaries
• Never guess doses - always check the BNF
• Always double check your prescription you are
  legally responsible for it

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Example
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Completing a Prescription Chart

• Mickey Mouse has been admitted to your ward and
  you have to compete his drug chart from the GP
  repeat slip
• Atenolol 25mg od
• Diclofenac 50mg tds
• GTN spray prn
• The decision has been made to start with
• 1) IV antibiotic therapy and the drug of choice
  is cefuroxime 1g tds
• 2) Paracetamol prn for pain
• Other information available states that he is
  penicillin allergic and weighs 60kg

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Parenteral Administration Chart
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Parenteral Administration In some hospitals it is
part of the usual drug chart
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TTO or TTA (To Take Out)

• What is it actually?

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Warfarin Chart
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Subcutaneous Insulin
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Insulin Chart
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FP10

• Hospital Community
• Various colours

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Drug Calculations

• Strength you want Strength
  you've got it in

x
amount required
Volume youve got it in
Watch out for Pharmaceutical preparations -
suppositories - liquids to tablets or vice versa
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IV Medication

• Check Drug indications dosages as in BNF
• BNF Appendix 6 guidelines additives
• To be written on Drug Chart NOT Fluid Chart
• ? Trust IV handbook ?
• KCL strong solution now handled as CD

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PrescribingWhere Do Errors Occur?

• Prescribing process - completing drug chart
  transcription from GP note / Pts own medicine
  - re-writing the drug chart - writing the TTO -
  insufficient discharge information
• Dispensing process - illegible writing
• Administration of medication - illegible writing
  on drug chart - unclear instructions
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

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Transcription Error
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Methotrexate Folic Acid
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Allergies Interactions
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Incomplete Drug Chart
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Never Abbreviate

• Micrograms
• Units or iuTinzaparin 3500u

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TTOs Lack of Information

• Discharge information needs to be improved to
  prevent prescribing errors
• Better training for HOs needed in completing
  TTOs
  - Pharmaceutical Journal Jan 2002

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Dose Error
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Specify dose

• Gliclazide 80mg
• Diclofenac50mg, 75mg or 100mg?
• Cipramil10mg or 20mg?

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GP Based Review of TTO Errors

• Total TTOs 268 28 errorsgt1 error/TTO
• Other findings - poor communication - changes
  in therapy not communicated

Northumbria Healthcare Trust
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Drug ChartTTO

• Formulation
• Route

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Incomplete TTO
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Incomplete TTO
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Completing a TTO
The decision is made to discharge Mr Henderson.
In addition to the drugs on his chart, the
pharmacist left you a green note indicating all
the other drugs that have been missed off. Can
you complete the TTO?

• Other drugs on this chart
• Ranitidine 150mg twice a day
• Allopurinol 100mg once daily
• Nicorandil 20mg once daily
• Aspirin 75mg once daily
• Sando K one twice daily
• GTN spray when required

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Transcription Error
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Bioavailability differences
No date or sig.
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Poor Handwriting Leading to Dispensing Error
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Poor Handwriting Leading to Dispensing Error
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Poor Handwriting Abbreviations
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TTO for the day

• STOP
• THINK
• ASK
• LISTEN
• LOOK

Its Your Responsibility!