Here is a 2/52 repeat prescription for Mrs Yellow for her chronic back pain: Morphine Sulphate MR capsules 20mg twice daily Please review patient regularly to monitor pain control and side effects. Maximum 2 months' supply. Review in 6 weeks or if concerns arise.

1. Medication Incidents
& safe prescribing
FY2 (part 2 of 2)
2016

2. Over View
• Case studies and prescribing (40 min)
• Golden tips on safe prescribing (10 min)

3. Case ONE: Mr Green
Mr Green (1111222) 72 year old male, Admitted to MFE
ward with SOB and a productive cough.
PMHx High cholesterol, OA, Parkinson’s disease
DHx: see next slide, NoK has a bag of drugs
Allergies: Penicillin, Doxycycline
• O2 sats: 82% OA
• Scattered wheezes heard on auscultation.
• Temp: 38.2.
• WBC 17.2, CRP 113.
• U+E N (Urea 5mmol/l)
• RR: 18
• BP: 121/71
∆ ?CA-LRTI In the mean time write up Mr Greens drug chart

4. Daily
2 QDS prn
1 on
1 TDS
1 min

7. • NO
Metoclopramide
• Parkinsons
patient
Regular Prescriptions 2
Date 
Circle times or enter other times
26/9
4. Drug (approved name)
Rotigotine
Start Date
26/9/14
06
08
Dose
6mg/24hrs
Route
Top(Patch)
Frequency
Once daily
12
14
Reason for starting / stopping
Parkinsons Disease
Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
5. Drug (approved name)
Simvastatin
Start Date
26/9/14
06
08
Dose
40mg
Route
po
Frequency
Once Daily
12
14
Reason for starting / stopping
High cholesterol
Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
6. Drug (approved name) Start Date 06
As Required Prescriptions 1
1. Drug (approved name)
Sodium Chloride 0.9%
Start Date
On admission
Date/
Time
Dose
5 mL
Route
IV
Pharm:
STOCK Route
Maximum Frequency
See Trust Protocol
To flush peripheral cannula, flushes for
other types of IV line must be prescribed.
Dose
Prescriber’s Signature
As per Trust Drug Protocol 1.2
Given
By
2. Drug (approved name)
Co-dydramol 10/500
Start Date
26/9/14
Date/
Time
Dose Route Pharm: cc: DH New
STOCK/ POD / TTO / IP / CD Route
As Required Prescriptions 1
1. Drug (approved name)
Sodium Chloride 0.9%
Start Date
On admission
Date/
Time
Dose
5 mL
Route
IV
Pharm:
STOCK Route
Maximum Frequency
See Trust Protocol
To flush peripheral cannula, flushes for
other types of IV line must be prescribed.
Dose
Prescriber’s Signature
As per Trust Drug Protocol 1.2
Given
By
2. Drug (approved name)
Co-dydramol 10/500
Start Date
26/9/14
Date/
Time
Dose
Ii
Route
po
Pharm: cc: DH New
STOCK/ POD / TTO / IP / CD Route
Maximum Frequency
qds
Indication / Other Instructions
pain Dose
Prescriber’s Signature
Hbassi
Bleep No
1287
Given
By
3. Drug (approved name) Start Date
Date/
Time

8. What is Mr Green’s CURB score?
Age>65years
CURB score of 1
Prescribe antibiotic(s)
1 min

10. How many opted for:
Amoxicillin
Clarithromycin
Doxycycline
Co-amoxiclav
Tazocin

11. Community Acquired Pneumonia
Mod severity
Antibiotic policy recommends
Amoxicillin 500mg tds po
plus
clarithromycin 500mg bd po 7 days
Penicillin allergy:
Doxycycline 200mg po stat then 100mg-200mg
od 7 days

12. Antibiotics Only
Review IV route daily
Antibiotics Only
Review IV route daily
Antibiotic Prescriptions 1 Indication and stop or review date MUST be completed
On review consider if IV route necessary refer to Trust policy for further guidance
Date
Circle times or enter other times
1. Antibiotic (approved name)
Clarithromycin
Start Date
26/9/14
06
08
Dose
500mg
Route
po
12
14
Frequency/Other Instructions
Twice daily
Supply
POD ( ) TTO /IP/Stock/Fridge
Sign: Date:
18
22
Indication(s)
LRTI
cc Date
DHx
New
24
Prescriber’s Signature
HBassi
Bleep No
1287
Initial Stop /Review Date
5/7
Revised Stop/Review Date Revised Stop/Review Date
4. Drug (approved name)
Simvastatin
Start Date
26/9/14
06
08
Dose
40mg
Route
po
Frequency
Once Daily
12
14
Reason for starting / stopping
High cholesterol
Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22 X X X X X
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
Hold while co-prescribed Macrolide (clarithromycin)
5. Drug (approved name) Start Date 06
Regular Prescriptions 2
7/7
Xx/xx/xx
Xx/xx/xx

13. Case Two: Mrs Brown
Mrs Brown (55667789) admitted to A&E with
confusion 2° to UTI, now successfully being treated
with Trimethoprim 200mg BD 5/7. Her vitals are
currently stable
PMHx: CCF, High cholesterol, OA (will not take
Bisposponates)
DHx: see bag of drugs
Allergies: NKDA
The cases is handed over to you, as the FY2 to write
up her drug chart.

14. Mrs Brown
takes all of
these
tablets
once a
day

17. Regular Prescriptions 2
Date 
Circle times or enter other times
26/9
4. Drug (approved name)
Adcal D3
Start Date
26/9/14
06
08
Dose
One
Route
po
Frequency
Once daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
5. Drug (approved name)
Digoxin
Start Date
26/9/14
06
08
Dose
250micrograms
Route
po
Frequency
Once Daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
6. Drug (approved name)
Simvastatin
Start Date
26/9/14
06
08
Xx/xx/xx
Xx/xx/xx

18. Duplication
• Simvastatin and Bezafibrate both given for
hypercholerstolaemia
• High risk drug?  No
• Acute indication?  No
• Confirm with a second source (Medicines
reconciliation)

19. Medicines reconciliation
• Pharmacist confirms that Bezafibrate was
stopped and replaced with Statin.
• All of the other tablets are correct however Mrs
Brown was started on the following by her GP
last month Amlodipine 10mg OD

20. Regular Prescriptions 2
Date 
Circle times or enter other times
26/9
4. Drug (approved name)
Adcal D3
Start Date
26/9/14
06
08
Dose
One
Route
po
Frequency
Once daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
5. Drug (approved name)
Digoxin
Start Date
26/9/14
06
08
Dose
250micrograms
Route
po
Frequency
Once Daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
6. Drug (approved name)
Simvastatin
Start Date
26/9/14
06
08
Dose
40mg
Route
Po
Frequency
Once daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
7. Drug (approved name)
Simvastatin
Start Date
26/9/14
06
08
Dose
20mg
Route
Po
Frequency
Once daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
8. Drug (approved name)
Amlodipine
Start Date
26/9/14
06
08
Dose
10mg
Route
Po
Frequency
Once daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
9. Drug (approved name) Start Date 06
STOP dose reduced due to
interaction with
amlodipine. HBassi #1287
26/9/14
Xx/xx
Xx/xx
Xx/xx
Xx/xx
Xx/xx

21. MHRA guidance
Drug interactions associated with increased risk of myopathy/rhabdomyolysis
Interacting agents Prescribing recommendations
Itraconazole
Ketoconazole
Posaconazole
Erythromycin
Clarithromycin
Telithromycin
HIV protease inhibitors (eg, nelfinavir)
Nefazodone
Ciclosporin
Danazol
Gemfibrozil
Contraindicated with simvastatin
Other fibrates (except fenofibrate) Do not exceed 10 mg simvastatin daily
Amiodarone
Amlodipine
Verapamil
Diltiazem
Do not exceed 20 mg simvastatin daily
Fusidic acid
Patients should be closely monitored. Temporary
suspension of simvastatin treatment may be
considered.
Grapefruit juice Avoid grapefruit juice when taking simvastatin

22. Case Three: Mrs Pink
You are on-call and asked to see Mrs Pink
(22335544).
She was admitted to EAUS for a planned TKR
however unsuitable for surgery, her BP has
been dropping since admission. Currently
87/58mmHg
Unable to access her EMPA drug chart

23. Nurse informs
you patient is
currently
prescribed One
of each…..
-Amiodarone
100mg od
-Amlodipine
10mg od
-Atenolol 75mg
od
-as per her bag
of drugs

24. Don’t assume.
• Confirm atenolol dose.
– 25mg
– 50mg
– 75mg?
• Amiodarone and atenolol interaction
(negative chronotropic ) thus confirm the
dose!
• Even with electronic prescribing we INPUT into the
system. Errors are two fold now:
– System errors (EMPA/drug charts/ICE)
– User errors (us lot)

25. Pharmacist
confirms
following 3
drugs…… all
ONCE daily

26. Regular Prescriptions 2
Date 
Circle times or enter other times
26/9
4. Drug (approved name)
Atenolol
Start Date
26/9/14
06
08
Dose
25mg
Route
po
Frequency
Once daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
5. Drug (approved name)
Amiodarone
Start Date
26/9/14
06
08
Dose
100mg
Route
po
Frequency
Once Daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
6. Drug (approved name)
amlodipine
Start Date
26/9/14
06
08
Dose
10mg
Route
Po
Frequency
Once daily
12
14
Reason for starting / stopping Supply
POD ( ) TTO /IP/Stock/CD /Fridge
Sign: Date:
18
22
Prescriber’s Signature
HBassi
Bleep No
1287
cc Date
DHx
New
24
7. Drug (approved name) Start Date 06
Xx/xx/xx
Xx/xx/xx
Xx/xx/xx
Can you see a
potential error here?
Electronic systems –
alphabetised – reading
in a rush

27. Case Four: Mrs Blue
• Admitted to AMU-L via ambulance.
• See clinical notes
• You are asked to write up the drug chart for
this lady
• Mr Blue has documented Mrs Blue’s acute
past medical history and Drug history in a
letter

28. Drug name Form Dose frequency

30. Drug Husbands List TTO GP list
Buprenorphine - - Yes
Candesartan Yes Yes Yes
Lercandipine 20mg od Yes Yes Yes
Simvastatin Yes Yes Yes
Adcal d3 Yes Yes Yes
Aspirin Yes Yes Yes
Atenolol Yes Yes Yes
Bendro Yes Yes Yes
Moxonidine - Yes -
Alendronic acid - Yes -

31. Drug Husbands List Old TTO 2012 GP list
Buprenorphine Check patient - Yes
Candesartan Yes Yes Yes
Lercandipine 20mg od Yes Yes Yes
Simvastatin Yes Yes Yes
Adcal d3 Yes Yes Yes
Aspirin Yes Yes Yes
Atenolol Yes Yes Yes
Bendro Yes Yes Yes
Moxonidine STOP - Yes -
Alendronic acid STOP - Yes -

34. Case Five: Mrs Yellow
You are a GP and one of your regular patients, Mrs
Yellow (2/8/1962, 13 mountain way, any town,
NM90KL) comes to see you for a regular prescription.
PHx: Chronic back pain, depression
DHx: Morphine Sulphate MR 20mg BD, Citalopram
10mg OD
Allergies: NKDA
You are keen to control her pain but monitor her
progress regularly so write a 2/52 repeat prescription

35. BNF
Zomorph® (Archimedes)
Capsules , m/r, morphine sulfate
10 mg (yellow/clear enclosing pale yellow pellets),
net price 60-cap pack = £3.47;
30 mg (pink/clear enclosing pale yellow pellets),
60-cap pack = £8.30;
60 mg (orange/clear enclosing pale yellow pellets),
60-cap pack = £16.20;
100 mg (white/clear enclosing pale yellow pellets),
60-cap pack = £21.80;
200 mg (clear enclosing pale yellow pellets), 60-cap
pack = £43.60. Label: 2, counselling, see below
Dose every 12 hours, dose adjusted according to
daily morphine requirements; for further advice on
determining doses, see Prescribing in Palliative
Care; dosage requirements should be reviewed if
the brand is altered

36. 2/8/1962 Mrs Yellow
13 mountain way,
Any town, NM90KL
Please supply
Citalopram 10mg OD x 1op
Morphine Sulphate
Modified release Capsules
20mg Twice daily,
total supply of (Fifty six)
56 x 10mg capsules
/////
Hbassi x/y/zz
Not an error – but
slows down patients
receiving drugs
Checking in the BNF
Easier – call the
pharmacy and check
stock/strengths
available

37. Revision of common Pall care
agents and doses
• Nausea & Vomiting
– Haloperidol 2.5-10mg/24hrs
– Cyclizine 150mg/24hrs
– Metoclopramide 30-120mg/24hrs
– Levomepromazine 6.25-25mg/24hrs
• Anxiety/aggitation
– Midazolam 10-60mg/24hrs
– Haloperidol 10-30mg/24hrs
– Levomepromazine 25-200mg/24hrs
• Pain
– Diamorphine patient specific doses
– Morphine – patient specific doses
– Alfentanyl – patient specific doses
• Respiratory secretions
– Hyoscine hydrobromide 600mcg-2.4mg/24hrs

38. What is
Safe
prescribing?

39. What are the two common
causes for prescribing errors?
• Time pressure
• Prescribing in isolation
Resilience
• Recognise triggers
• Rushed
• New drugs
• Someone breathing down your neck
• High risk drugs
• Time sensitive drugs
  Slow down & double check

40. High risk drugs
• Methotrexate
• Anticoagulants
• Injectable medicines
• Epidurals
• Oral chemotherapy
• Oral opiates
• Medical gases
• Insulin
• Parkinsons

41. Drugs with time-sensitivity
• Anticoagulants, antiplatelets, thrombolytics
• Antiepileptics
• Anti-parkinsonians
• Anti-diabetics (insulin & oral hypoglycaemics)
• Antimicrobials (systemic routes only)
• Steroids
• Immunosuppressants
• Chemotherapy & associated adjunctive therapy
• Electrolyte correcting agents
• Anti-arrhythmics
• Anti-anginal agents

42. Thank you for listening ….
Any questions?