rational prescribing & prescription writing

2. Rational prescription writing
By
M. H. Farjoo , M.D. , Ph.D. , Bioanimator
Shahid Beheshti University of Medical Sciences

3. Rational prescription writing
 Introduction
 P-drugs
 Steps in Prescription writing
 Information & instructions for the Patient
 Common Abbreviations
 Common Measures and Clark's rule
 A deadly Weapon
 Do Not Use List
 Electronic Prescribing

4. Introduction
 Pharmacotherapy teaching is NOT the transfer of
knowledge about drugs, but the skill to treat patients.
 The students should be taught how to prescribe, not
what.
 Irrational prescribing is a “disease” which is difficult
to treat
 Prescribing is not a knee-jerk reflex, a recipe from a
'cook-book', or a response to commercial pressure.

7. Introduction
 A survey in Iran in 1393 showed 20% of all the
medical errors were pharmaceutical as below:
 39% prescription errors by physicians
 38% administration errors by nurses
 12% pharmacists and prescription fillers errors
 11% hospital staff errors while transferring physician order
to the nursing files

9. http://www.fda.gov.ir/
‫پزشکی‬ ‫مات‬‫و‬‫ملز‬ ‫و‬ ‫ات‬‫ز‬‫تجهی‬ ،‫یی‬‫و‬‫دار‬ ‫ض‬‫ر‬‫عوا‬ ‫ش‬‫ر‬‫ا‬‫ز‬‫گ‬‫ثبت‬ ‫سامانه‬

10. Introduction
 1.3 million people are injured and 7000 deaths occur each
year in the U.S from medication-related errors.
 Drug-related morbidity and mortality cost $177 billion in
the U.S.
 If there are 800,000 physicians in the United States, each
physician accounts for more than $220,000!
 What is a Medication Error? A medication error is any
preventable event…
 It is not important what is the rest of the definition!
 The important point is: it is preventable!

13. • www.ismp.org
(institute for safe medication practice)
• www.nccmerp.org
(National Coordinating council for medication Error
Reporting and prevention)
• www.who-umc.org
• www.fda.gov/medwatch
• http://www.fda.gov.ir/
• Journal of risk & safety in medicine
• Text book of medication Errors Edited by Michael R
Cohen.
How To Keep Up-To-Date

14. www.ismp.org

15. www.nccmerp.org

16. www.who-umc.org

17. www.fda.gov/medwatch

18. http://www.medscape.com/

20. Martindale 2017

23. IDL

26. P-drugs
 A physician should develop a standard treatment for
common disorders, resulting in a set of first-choice drugs,
called p(ersonal)-drugs.
 Efficacy is the first criterion for selection.
 Look for groups of drugs rather than individual drugs.
 The patient should be able to administer the drug alone.
 Drugs for elderly and children should be in convenient
dosage forms.
 Consider cost of treatment.

27. Steps in Prescription writing
1. Make a specific diagnosis.
2. Consider the pathophysiologic implications of the
diagnosis.
3. Select a specific therapeutic objective.
4. Select a drug of choice.
5. Determine the appropriate dosing regimen: Strength,
Amount, Route, Frequency, Refills
6. Devise a plan for monitoring the drug’s action and
determine an end point for therapy.
7. Plan a program of patient education.

28. Hi there!
Pleas! Write
legible
God damn it!
Write legible!

33. Information & instructions for the Patient
 Effects of the drug
 Why the drug is needed
 Which symptoms will disappear, and which will not
 When the effect is expected to start
 What will happen if the drug is taken incorrectly or not at
all
 Side effects
 Which side effects may occur
 How to recognize them
 How long they will continue
 How serious they are
 What action to take

34. Information & instructions for the Patient
 Instructions
 How the drug should be taken
 When it should be taken
 How long the treatment should continue
 How the drug should be stored
 What to do with left-over drugs
 Warnings
 When the drug should not be taken
 What is the maximum dose
 Why the full treatment course should be taken

35. Information & instructions for the Patient
 Future consultations
 When to come back (or not)
 In what circumstances to come earlier
 What information the doctor will need at the next
appointment
 Everything clear?
 Ask the patient whether everything is understood
 Ask the patient to repeat the most important information
 Ask whether the patient has any more questions

36. Information & instructions for the Patient
 Monitor (and stop?) the treatment
 Passive monitoring:
you explain to the patient what to do if the
treatment is ineffective, inconvenient or if many
side effects occur.
 Active monitoring
you make an appointment to determine yourself
whether the treatment has been effective.

37. Common Abbreviations
 PO (by mouth)
 PR (per rectum)
 IM (intramuscular)
 IV (intravenous)
 ID (intradermal)
 IN (intranasal)
 TP (topical)
 SL (sublingual)
 BUCC (buccal)
 IP (intraperitoneal)

38. Common Abbreviations
 Daily (no abbreviation)
 Every other day (no abbreviation)
 BID/b.i.d. (Twice a Day)
 TID/t.id. (Three Times a Day)
 QID/q.i.d. (Four Times a Day)
 QHS (Every Bedtime)
 Q4h (Every 4 hours)
 Q4-6h (Every 4 to 6 hours)
 QWK (Every Week)

39. Common Measures
 1 Teaspoonful = 5 mL
 1 Tablespoonful = 15 mL
 20 Drops = 1 mL
 2.2 Pounds (lb) = 1 Kilogram (kg)

40. Clark's rule
 Clark's rule is used to calculate the proper dosage of
medicine for children aged 2–17.
 Take the child's weight in Kg, and divide by 68 Kg
(actually 68.04 Kg).
 Then multiply the result by the adult dose.
 The answer is the equivalent child dosage.

41. A deadly Weapon
• Look at a weapon of mass Destruction:
• Be careful of the dots and zeroes!

42. “Do Not Use” List
 U or u (unit) – use “unit”
 IU (International unit) – use “International Unit”
 Q.D./QD/q.d./qd – use “daily”
 Q.O.D./QOD/q.o.d./qod – use “every other day”
 Trailing zeros (#.0 mg) – use # mg
 Lack of leading zero (.#) – use 0.# mg
 MS – use “morphine sulfate” or “magnesium sulfate”
 MS04 and MgSO4 – use “morphine sulfate” or
“magnesium sulfate”

43. “Do Not Use” List
 “ASA” (aspirin), “5-ASA” (5-aminosalicylic acid),
“6MP” (6-mercaptopurine), etc, should not be used
 Drug names should be written out.
 Unclear handwriting can be lethal.
 Acetazolamide / acetohexamide, or methotrexate /
metolazone are easily mistaken.
 In this situation, write the indication for the drug in the
body eg: “acetazolamide, for glaucoma.”
 Do not use vague instructions eg: “Take as directed or
as needed” as the sole direction.

45. “Do Not Use” List
 The most 3 important points in abbreviations
are:
1. Do Not Use Abbreviations!!
2. Do Not Use Abbreviations!!
3. Do Not Use Abbreviations!!

46. Electronic Prescribing
 Electronic or e-prescribing is the transmission of
prescription from the prescriber's computer to a
pharmacy computer.
 The software may suggest alternative drugs that are
either more effective or less costly.
 Prescribers should move to a direct computerized,
order entry system

47. Beneath the rule of men entirely great,
the pen is mightier than the sword...
Edward Bulwer-Lytton, 1839
..and can be just as deadly!!
J. Sabino, 2012

49. Thank you
Any question?

50. 1387
‫تجویز‬ ‫اصول‬
‫دارو‬ ‫منطقی‬
‫معاونت‬ ‫انتشارات‬ ‫از‬
‫دارو‬ ‫و‬ ‫غذا‬
‫و‬ ‫بهداشت‬ ‫وزارت‬
‫درمان‬

51. 2012
Katzung
Basic & Clinical
Pharmacology
12th Edition
Chapter 65
Rational
Prescribing &
Prescription
Writing

53. ‫دستورالعم‬ ‫و‬ ‫قوانین‬ ،‫بیمه‬ ‫با‬ ‫آشنائی‬‫لها‬
‫انواع‬‫بیمه‬:،‫خصوصی‬،‫دولتی‬،‫پایه‬،‫مکمل‬،‫بازرگانی‬‫درمانی‬...
‫تعاریف‬:‫بیمه‬،‫گر‬‫بیمه‬،‫شده‬‫حق‬،‫بیمه‬‫فرانشیز‬...
‫بیمه‬‫های‬‫سالمت‬:‫پایه‬(Basic)،‫مازاد‬(Alternative)،‫مکمل‬(Supplementary)
‫انواع‬‫بیمه‬‫در‬‫کشور‬:
.1‫تامین‬‫اجتماعی‬:،‫اجباری‬،‫اختیاری‬،‫مشاغل‬‫مستمری‬،‫بگیر‬،‫ازکارافتاده‬‫ب‬‫یکاری‬
.2‫خدمات‬‫درمانی‬:‫کارکنان‬،‫دولت‬،‫روستائیان‬‫خویش‬،‫فرما‬‫سایر‬،‫اقشار‬‫بس‬‫تری‬
.3‫نیروهای‬‫مسلح‬:،‫شاغلین‬،‫وابستگان‬‫بازنشستگان‬
.4‫کمیته‬‫امداد‬:،‫شهری‬‫روستائی‬
.5‫بانک‬‫ها‬،‫شهرداری‬...
‫نحوه‬‫ارائه‬‫خدمات‬:،‫مستقیم‬،‫کارت‬‫دفترچه‬
‫قوانین‬:،‫قرارداد‬،‫ضوابط‬،‫تعهدات‬،‫بازرسی‬،‫تعرفه‬،‫فرانشیز‬‫شکایت‬....

57. ‫دانشجو‬ ‫خانوادگی‬ ‫نام‬ ‫و‬‫نام‬:‫مربوطه‬‫استاد‬:
‫دانشجوئی‬ ‫ه‬‫ر‬‫شما‬:‫ودی‬‫ر‬‫و‬: