Grzegorz Chodkowski (MD) Riga, Radisson SAS 2009 BNF, Pharmacology  and Prescribing in the NHS
BNF
BNF   British National Formulary <ul><li>Published twice a year ( March/October ) </li></ul><ul><li>by  </li></ul><ul><li>...
The History
BNF Today <ul><li>Provides: </li></ul><ul><li>Guidance on prescribing </li></ul><ul><li>Relevant information on prescripti...
 
 
 
Appendix
The BNF is… <ul><li>The best available </li></ul><ul><li>Up to date – published every 6 months </li></ul><ul><li>Succinct ...
Who gets the BNF in the UK? <ul><li>About 250,000 copies are published which go to all : </li></ul><ul><li>Doctors </li></...
Who gets the BNF overseas? <ul><li>Licensed translations for Spain, Turkey and Italy </li></ul><ul><li>Unlicensed use in m...
 
The BNF for Children – BNFC <ul><li>Children are a challenge  </li></ul><ul><li>Come in different sizes </li></ul><ul><li>...
 
 
M edicines and  H ealthcare products  R egulatory  A gency
The Yellow Card Reporting of suspected Adverse Drug Reactions by health professionals and patients Routine publication of ...
Publications The MHRA currently publishes some 80 types of output, which are now being reviewed as part of the Agency’s co...
Pharmacology
drops eye  /oral  drops aerosol spray nasal spray patch dry powder for inhalation aerosol pessary foam solution gel vagina...
Drug d osage lat. quaque seconda hora  / every 2-nd hour q2h lat. quaque hora  / every hour qh at night noctè lat. statim ...
Routes of Administration topical top. per rectum p.r by mouth / orally p.o intra-articular i.a topical top. subcutaneus s....
Routes of Administration sublingual SL Percutaneous Endoscopic Jejunostomy PEJ Percutaneous Endoscopic Gastrostomy PEG Nas...
Basic drug groups <ul><li>analgesics (pain killers) </li></ul><ul><li>antiemetics </li></ul><ul><li>antidiarrhoeals </li><...
Controlled Drugs
Controlled Drugs
Pain managment Paracetamol   500mg 1-2 tabl. every 4-6 h max. 4h daily i.v >>>(Parfalgan) 1g for15min. every 4-6h, max. 4g...
NSAIDs (Non-steroidal anti-inflammatory drugs) Diclofenac   ( Voltrol  ® )    75mg-150mg p.o tds/qds 75mg o.d i.m   max. t...
Anti-emetics Ondansetron  (Zofran  ®  ) 0.15mg / kg i.v for 15min usually 4mg,  also deeply  i.m  Cyclizine  50mg p.o / i....
Antibiotics <ul><li>Most common:  </li></ul><ul><li>PENICILINES </li></ul><ul><li>Amoxicilin </li></ul><ul><li>Augmentin <...
Fluid balance assesment <ul><li>crackles over lungs </li></ul><ul><li>skin tone </li></ul><ul><li>JVP  </li></ul><ul><li>c...
Prescribing <ul><li>PoM – Prescribing Only Medicines „…it is important to discuss treatment options carefully with the pat...
Prescribing Standard <ul><li>prescription should be in black ink or computer generated </li></ul><ul><li>legible writting ...
The standard <ul><li>‘ micrograms’ and ‘nanograms’ and ‘units’ should not  be abbreviated </li></ul><ul><li>know & documen...
<ul><li>Amoxicilin  oral suspension </li></ul><ul><li>125mg/5mL sugar free </li></ul><ul><li>125mg three times daily </li>...
Antacids <ul><li>- Aluminium hydroxide 1-2 tablets chewed </li></ul><ul><li>Magnesium Carbonate 10mls t.d.s </li></ul><ul>...
Sleeping medications Temazepam   10 - 20 mg noct è Lorazepam  0.5 - 1mg noct è Zopiclone  3.75 - 7.5 mg noct è Nytol   25m...
Intravenous managment <ul><li>Purpose: </li></ul><ul><li>- fluid balance managment </li></ul><ul><li>- replacement of lost...
Pre-op routine <ul><li>sedation (benzodiazepines - Diazepam) </li></ul><ul><li>>reversal agent: Flumazenil   </li></ul><ul...
Proton Pump Inhibitors Omeprazole  (Losec  ® ) 20mg od Pantoprazole  Lansoprazole  (Zoton  ® ) 30mg od
Prescribing
 
Patients Vary
<ul><li>Know the medicine well enough to administer safely   </li></ul><ul><li>Check and be certain of patient identity  <...
<ul><li>Medication prescribing is:  </li></ul><ul><ul><li>Appropriate  </li></ul></ul><ul><ul><li>Safe  </li></ul></ul><ul...
<ul><li>The Allergy box must not be left empty  </li></ul><ul><li>Use approved names (rINN) in black ink and BLOCK CAPITAL...
<ul><li>Safe prescribing depends upon you putting yourself in the mind of everyone who might read and act on your script, ...
<ul><li>Methotrexate given daily instead of weekly  </li></ul><ul><li>Writing ug for microgram which might be read as mg a...
 
No Stamp
 
 
 
 
 
 
 
 
Package inserts <ul><li>Dosage and directions for use </li></ul><ul><li>Side-effects and special precautions </li></ul><ul...
 
<ul><li>Thank You! </li></ul><ul><li>Any Questions? </li></ul>
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B N F, Pharmacology And Prescribing In The N H S

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B N F, Pharmacology And Prescribing In The N H S

  1. 1. Grzegorz Chodkowski (MD) Riga, Radisson SAS 2009 BNF, Pharmacology and Prescribing in the NHS
  2. 2. BNF
  3. 3. BNF British National Formulary <ul><li>Published twice a year ( March/October ) </li></ul><ul><li>by </li></ul><ul><li>British Medical Association </li></ul><ul><li>& Royal Pharmaceutical Society of Great Britain </li></ul><ul><li>www.bnf.org </li></ul><ul><li>FREE ! on-line access by users from Latvia </li></ul>
  4. 4. The History
  5. 5. BNF Today <ul><li>Provides: </li></ul><ul><li>Guidance on prescribing </li></ul><ul><li>Relevant information on prescription drugs in UK </li></ul><ul><li>Appendices on drug interactions and </li></ul><ul><li>prescribing in pregnancy, whilst </li></ul><ul><li>breast feeding and for those with liver </li></ul><ul><li>or kidney disease </li></ul>
  6. 9. Appendix
  7. 10. The BNF is… <ul><li>The best available </li></ul><ul><li>Up to date – published every 6 months </li></ul><ul><li>Succinct </li></ul><ul><li>Accurate </li></ul><ul><li>Also available as BNF.org </li></ul>
  8. 11. Who gets the BNF in the UK? <ul><li>About 250,000 copies are published which go to all : </li></ul><ul><li>Doctors </li></ul><ul><li>Medical students </li></ul><ul><li>Pharmacists </li></ul><ul><li>Pharmacy students </li></ul><ul><li>Hospital wards and clinics </li></ul><ul><li>Plus dentists and nurse prescribers </li></ul>
  9. 12. Who gets the BNF overseas? <ul><li>Licensed translations for Spain, Turkey and Italy </li></ul><ul><li>Unlicensed use in many countries </li></ul><ul><li>Pharmaid sends 6-12 month old BNFs to Commonwealth countries </li></ul><ul><li>BNF.org available across the world </li></ul>
  10. 14. The BNF for Children – BNFC <ul><li>Children are a challenge </li></ul><ul><li>Come in different sizes </li></ul><ul><li>Grow and develop </li></ul><ul><li>and </li></ul><ul><li>Clinical trials difficult </li></ul><ul><li>Data very limited </li></ul><ul><li>Many drugs not licensed for use in children </li></ul>
  11. 17. M edicines and H ealthcare products R egulatory A gency
  12. 18. The Yellow Card Reporting of suspected Adverse Drug Reactions by health professionals and patients Routine publication of aggregated yellow card data on the MHRA web site
  13. 19. Publications The MHRA currently publishes some 80 types of output, which are now being reviewed as part of the Agency’s communication strategy
  14. 20. Pharmacology
  15. 21. drops eye /oral drops aerosol spray nasal spray patch dry powder for inhalation aerosol pessary foam solution gel vaginal gel ointment injection syrup suspension oral suspension suppository granule c apsule tablet effervescent / soluable / dispersible / coated tablet
  16. 22. Drug d osage lat. quaque seconda hora / every 2-nd hour q2h lat. quaque hora / every hour qh at night noctè lat. statim / at once stat lat. pro re nata / as and when required p.r.n lat. quarter in die lat. quarter in die lat.quater in die summendus four times daily qd q.i.d q.d.s lat. ter in diem summendum lat. ter in die three times daily t.d.s t.i.d lat. bis in die / two times daily b.i.d once daily od omni mane / every morning omni nocte / every night o.m o.n
  17. 23. Routes of Administration topical top. per rectum p.r by mouth / orally p.o intra-articular i.a topical top. subcutaneus s.c intravenous i.v intra-muscular intra-peritoneal i. m i.p English Abbreviation Latvian
  18. 24. Routes of Administration sublingual SL Percutaneous Endoscopic Jejunostomy PEJ Percutaneous Endoscopic Gastrostomy PEG Naso-jejunal tube NJ i nhalation Inh Naso-gastric tube nebulisation NG Neb English Abbreviation Latvian
  19. 25. Basic drug groups <ul><li>analgesics (pain killers) </li></ul><ul><li>antiemetics </li></ul><ul><li>antidiarrhoeals </li></ul><ul><li>anti-inflammatories </li></ul><ul><li>antihistamines </li></ul><ul><li>antihypertensives </li></ul><ul><li>anti-anxiety drugs </li></ul><ul><li>antibiotics </li></ul><ul><li>antacids </li></ul><ul><li>proton pump inhibitors </li></ul><ul><li>anti-arrhythmics </li></ul><ul><li>anticoagulants </li></ul><ul><li>anticonvulsants </li></ul><ul><li>laxatives </li></ul><ul><li>sex hormones </li></ul><ul><li>sleeping drugs </li></ul>antipyretics antispasmodics antivirals beta-blockers bronchodilators cold cure remedies corticosteroids cough suppresants cytotoxics diuretics decongestants hormones hypoglycaemics Immunosuppresants vasodilators vitamins
  20. 26. Controlled Drugs
  21. 27. Controlled Drugs
  22. 28. Pain managment Paracetamol 500mg 1-2 tabl. every 4-6 h max. 4h daily i.v >>>(Parfalgan) 1g for15min. every 4-6h, max. 4g daily Paracetamol + codeine every 4-6h Co-Codamol – 500/8 mg Co-Dydramol – 500/10 mg Solpadol – 500/30 mg Mild narcotics (opiates) codeine 30-60 mg p.o/p.r >>>constipation!!!
  23. 29. NSAIDs (Non-steroidal anti-inflammatory drugs) Diclofenac ( Voltrol ® ) 75mg-150mg p.o tds/qds 75mg o.d i.m max. total daily dose 150mg Ketoprofen ( Orudis ® , Oruvail ® ) 50mg tds p.o
  24. 30. Anti-emetics Ondansetron (Zofran ® ) 0.15mg / kg i.v for 15min usually 4mg, also deeply i.m Cyclizine 50mg p.o / i..v / i.m TDS Metoclopramide (Maxolon ® ) 10mg i.v for 1-2 min TDS also p.o / i.m Post opiates/anaesthesia Phenothiazines best: Prochlorperazine : nausea > 20mg , po 2h 10mg prophylactics: 5-10mg 2-3 times / daily 25mg supp. initially, then after 6h changed for 5-10 mg p.o or deeply i.m 12.5mg, then after 6h changed for 5-10 mg p.o Chlorpromazine : 10-25mg every 4-6h p.o 25 mg i.m, followed by 25-50mg every 3-4h 100mg supp. every 6-8h
  25. 31. Antibiotics <ul><li>Most common: </li></ul><ul><li>PENICILINES </li></ul><ul><li>Amoxicilin </li></ul><ul><li>Augmentin </li></ul><ul><li>AMINOGLICOSIDES (When allergic to penicylines) Erythromycin </li></ul><ul><li>CHINOLONES Flucloxacilin Ciprofloxacin </li></ul><ul><li>CEPHALOSPORINES Cefuroxime (Zinacef ® ) 750mg i.v TDS </li></ul><ul><li>in surgical prophylaxis: 1.5g i.v pre-op, 750mg intra-op, 750mg post-op </li></ul>
  26. 32. Fluid balance assesment <ul><li>crackles over lungs </li></ul><ul><li>skin tone </li></ul><ul><li>JVP </li></ul><ul><li>capillary fill </li></ul><ul><li>HR / BP </li></ul><ul><li>urinary output </li></ul><ul><li>HgB </li></ul>
  27. 33. Prescribing <ul><li>PoM – Prescribing Only Medicines „…it is important to discuss treatment options carefully with the patient to ensure that the patient is content to take the medicine as prescribed…” </li></ul>
  28. 34. Prescribing Standard <ul><li>prescription should be in black ink or computer generated </li></ul><ul><li>legible writting </li></ul><ul><li>signed in ink by presciber </li></ul><ul><li>- drug names should not be abbreviated </li></ul><ul><li>prescription should include: </li></ul><ul><li>- full name and address of the patient </li></ul><ul><li>- age and DOB (optional) </li></ul><ul><li>but necessary in children under 12 </li></ul>
  29. 35. The standard <ul><li>‘ micrograms’ and ‘nanograms’ and ‘units’ should not be abbreviated </li></ul><ul><li>know & document allergies </li></ul><ul><li>weight </li></ul><ul><li>dose should be written in clear numbers, </li></ul><ul><li>without unnecessary decimal points </li></ul><ul><li>e.g 8mg not 8.0mg 1g not 1.0g 500mg not 0.5g </li></ul>
  30. 36. <ul><li>Amoxicilin oral suspension </li></ul><ul><li>125mg/5mL sugar free </li></ul><ul><li>125mg three times daily </li></ul><ul><li>Supply: 100ml </li></ul><ul><li>(No more items on this prescription) </li></ul>Sample prescribing
  31. 37. Antacids <ul><li>- Aluminium hydroxide 1-2 tablets chewed </li></ul><ul><li>Magnesium Carbonate 10mls t.d.s </li></ul><ul><li>Gaviscon 10-20 mls </li></ul><ul><li>H2 receptor antagonists </li></ul><ul><li>Ranitidine 150mg b.i.d </li></ul><ul><li>Proton Pump Inhibitors </li></ul><ul><li>Omeprazole 20mg o.d </li></ul>
  32. 38. Sleeping medications Temazepam 10 - 20 mg noct è Lorazepam 0.5 - 1mg noct è Zopiclone 3.75 - 7.5 mg noct è Nytol 25mg - 50mg noct è Diazepam 2mg – 5mg noct è
  33. 39. Intravenous managment <ul><li>Purpose: </li></ul><ul><li>- fluid balance managment </li></ul><ul><li>- replacement of lost fluid </li></ul><ul><li>- Glucose / Dextrose </li></ul><ul><li>D5W – 5% Dextrose water </li></ul><ul><li>Normal Saline / 0.9 % Saline </li></ul><ul><li>Hartmann’s Solution </li></ul><ul><li>Ringers Solution </li></ul>
  34. 40. Pre-op routine <ul><li>sedation (benzodiazepines - Diazepam) </li></ul><ul><li>>reversal agent: Flumazenil </li></ul><ul><li>( 200 μ g over 15s followed by 100 μ g at 1min. Intervals) </li></ul><ul><li>stopping Warfarin </li></ul>
  35. 41. Proton Pump Inhibitors Omeprazole (Losec ® ) 20mg od Pantoprazole Lansoprazole (Zoton ® ) 30mg od
  36. 42. Prescribing
  37. 44. Patients Vary
  38. 45. <ul><li>Know the medicine well enough to administer safely  </li></ul><ul><li>Check and be certain of patient identity </li></ul><ul><li>Know the care plan </li></ul><ul><li>Administer in the context of patient condition </li></ul><ul><li>Check for allergy and the expiry date before administering </li></ul><ul><li>Know the following so you correct and understand prescription instructions:  </li></ul>Key Points
  39. 46. <ul><li>Medication prescribing is: </li></ul><ul><ul><li>Appropriate </li></ul></ul><ul><ul><li>Safe </li></ul></ul><ul><ul><li>Legible </li></ul></ul><ul><ul><li>Accurate </li></ul></ul><ul><ul><li>Clear </li></ul></ul><ul><ul><li>Indelible </li></ul></ul><ul><li>  </li></ul><ul><li>The patient must be identifiable </li></ul><ul><ul><li>patient's name </li></ul></ul><ul><ul><li>address </li></ul></ul><ul><ul><li>date of birth </li></ul></ul><ul><ul><li>hospital number </li></ul></ul><ul><ul><li>age if under 12 (legal requirement) </li></ul></ul><ul><ul><li>weight if under 12 (legal requirement) </li></ul></ul>Prescribing Core Knowledge (for all clinical staff)
  40. 47. <ul><li>The Allergy box must not be left empty </li></ul><ul><li>Use approved names (rINN) in black ink and BLOCK CAPITALS </li></ul><ul><li>Metric doses </li></ul><ul><li>Write micrograms and units in full </li></ul><ul><li>Indicate the route and times of administration </li></ul><ul><li>Administration times should be agreed with the nursing team and the 24-hour clock used. Specify precise times if important. </li></ul><ul><li>Do not alter existing prescriptions. Rewrite if a change is made. </li></ul><ul><li>Only one chart should be active </li></ul><ul><li>Discontinue a treatment by crossing through it and cancelling subsequent recording panels. Add your initials and the date. </li></ul><ul><li>Antibiotics must be prescribed for a stated time period. </li></ul><ul><li>Place X in administration box to indicate drug not to be given at specific time & day </li></ul><ul><li>If a drug is to be administered by a pre-prepared protocol or patient specific direction this must be explicitly referred to on the chart </li></ul>Prescription Chart Standards
  41. 48. <ul><li>Safe prescribing depends upon you putting yourself in the mind of everyone who might read and act on your script, patient, nurse, pharmacist and fellow prescriber.          </li></ul><ul><li>Dangerous errors tend to be: </li></ul><ul><li>Wrong medication in context </li></ul><ul><li>Wrong dose (too much) </li></ul><ul><li>Mistakes, are more likely when tired or distracted or interrupted. Every-one makes mistakes and every one will make the occassional bad mistake </li></ul><ul><li>Team work and taking responsibility for checking others and then acting appropriately is the most effective way of reducing patient harm. </li></ul><ul><li>All should accept the correction of potential mistakes in good grace  </li></ul><ul><li>Many safety issues are due to culture and can be corrected by system change </li></ul><ul><li>Insulin is the most common cause of administration error </li></ul><ul><li>Anticoagulants are the most common cause of life threatening prescribing error. </li></ul><ul><li>All clinical staff should know the risks with prescribing so they can be detected. </li></ul><ul><li>  </li></ul>Medicines Safety
  42. 49. <ul><li>Methotrexate given daily instead of weekly </li></ul><ul><li>Writing ug for microgram which might be read as mg and patient given 1000 times too much.  </li></ul><ul><li>Allergy box on drug chart left empty </li></ul><ul><li>Three fatal episodes where a prescriber prescribes a penicillin to someone documented to be allergic penicillin and the penicillin is given despite the allergy being stated on the wrist band(s) and drug chart  </li></ul><ul><li>A study comparing administration error in UK, Germany & France found </li></ul><ul><ul><li>Product not labelled/incorrectly labelled in 43%, 99% and 20% of doses  respectively </li></ul></ul><ul><ul><li>Wrong diluent used in 1%, 49% and 18% </li></ul></ul><ul><ul><li>Wrong administration selected for 49%, 21% and 5% of doses observed </li></ul></ul><ul><ul><li>At least one deviation from aseptic technique was observed among 100%, 58% and 19% </li></ul></ul><ul><ul><li>In the UK, no cleaning of preparation area or hand washing was observed for any of the prepared doses </li></ul></ul><ul><ul><li>Only 1% of cases swabbing the vial top </li></ul></ul><ul><ul><li>In the UK, the most frequent medication errors were related to an incorrect administration rate (48%).    </li></ul></ul>Examples:
  43. 51. No Stamp
  44. 60. Package inserts <ul><li>Dosage and directions for use </li></ul><ul><li>Side-effects and special precautions </li></ul><ul><li>Known symptoms of over-dosage and particulars of its treatment </li></ul><ul><li>Identification </li></ul><ul><li>Presentation </li></ul><ul><li>Storage instructions </li></ul><ul><li>Registration number or reference number </li></ul><ul><li>Name and address of the holder of the certificate of registration </li></ul><ul><li>Date of publication </li></ul>
  45. 62. <ul><li>Thank You! </li></ul><ul><li>Any Questions? </li></ul>
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