Prescribing II


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  • Thus, for every 300 pts treated, 8 die!!!!
  • Prescribing II

    1. 1. Prescribing Safely Narinder Bhalla Lead Pharmacist – Clinical Governance Addenbrooke’s NHS Trust March 2005
    2. 2. Objectives  What is a medication error?  What is a prescribing error?  Why do errors occur?  Different drug charts  Examples of common errors  High risk drugs  Good prescribing principles
    3. 3. What is the size of the problem? Every year in the NHS  400 die/seriously injured by medical devices.  10,000 have serious adverse reaction to a drug  Adverse events that lead to harm occur in 10% of hospital admissions.  28,000 written complaints about clinical treatment in hospital.  £400m to settle clinical negligence claims. (potential liability of £2.4 billion) (ref An Organisation with Memory)
    4. 4. When it goes wrong
    5. 5. 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 >1 in 10 pts 1/3 of these are serious In 8% of these cases, it lead to the patient’s death
    6. 6. To Err Is Human  Core curricula 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% The Audit Commission: A spoonful of sugar - medicine management in NHS hospitals
    7. 7. Definition of Medication Incident/Error A medication error is “A preventable prescribing, dispensing, drug Administration or clinical advice (relating to drugs) error.”
    8. 8. Causes of medication incidents  Fatigue: Sleep deprivation  Hunger: Long lapses between food/drink  Concentration: Lapses  Stress: Loss of control/cutting corners  Distraction  Lack of training  Lack of access to information (not timely)  Other factors: Alcohol, drugs & illness
    9. 9. Common Prescribing Errors  Wrong drug (e.g. drugs that sound alike)  Wrong dose  Inappropriate Units  Poor/illegible prescriptions  Failure to take account of drug interactions  Omission  Wrong route/multiple routes (IV/SC?PO)  Calculation errors (important in Paediatrics)  Poor cross referencing  Infusions with not enough details of diluent, rate etc. Poor cross-referencing between charts  Once weekly drugs  Multiple dose changes
    10. 10. Spot the difference? Look alike drugs contribute to medication errors
    11. 11. Spot the difference? Look alike drugs contribute to medication errors
    12. 12. Spot the difference? Look alike drugs contribute to medication errors
    13. 13. Lidocaine Administering the wrong drug could be fatal “NHS standard”:  Water  Sodium chloride  Lidocaine (lignocaine)
    14. 14. Examples Drugs that sound alike Clotrimazole/Co-trimoxazole Carbamazapine/carbimazole Risedronate/Methotrexate Drugs that look similar in writing ISMN / ISTIN
    15. 15. Once weekly drugs Oral methotrexate Methotrexate prescribed as 10mg once daily, when correct dose frequency is once weekly. Drug charts should be clearly marked as follows: - Regular Prescription s Month and date 19 /1 2 20 /1 2 21 /1 2 22 /1 2 23 /1 2 24 /1 2 25 /1 2 26 /1 2 27 /1 2 28 /1 2 29 /1 2 30 /1 2 Tick times or enter other times DRUG 6 METHOTREXATE 8  X X X X X X X X X X Dose Route Start Date 20.12.02 Stop Date 12 10mg PO 14 Signature Pharm 18 ONCE A WEEK - MONDAYS 4 X 2.5mg tabs 22 Similarly the above information should be clear on the TTO and any change should be communicated clearly to the patients GP.
    16. 16. Opioids Not always bioequivalent by different routes e.g. IM Morphine 10mg = 2.5-5mg IV Codeine Not given IV, the only licensed parentral route is IM Dihydrocodeine Not given IV, appropriate parentral routes are SC or IM. If codeine or dihydrocodeine given IV, 100% bioavailability therefore danger of respiratory depression and other opioid side-effects. Slow- release/Non- slow release formulations MST/Sevredol Oxycontin/Oxynorm
    17. 17. Cytotoxic Drugs  The same levels of care must apply whether a cytotoxic drug is being used to treat cancer or another indication e.g. rheumatology, dermatology.  The same levels of care must apply whether a cytotoxic drug is being used parenterally or orally.  Initiation of cytotoxic chemotherapy should be by a Consultant. Subsequent prescribing should be a Consultant or SpR.  Intravenous cytotoxics are prepared within a chemotherapy unit in Pharmacy.  Intravenous cytotoxics are only administered in specified areas in the hospital.  Any staff of any grade may not participate in ANY WAY in intrathecal administration of cytotoxics unless specifically accredited to do so. The only exception is observation with NO participation.
    18. 18. Examples Inappropriate units Insulin Mixtard 30 Dose 10 i.u. – could be read as 101 units Drug Interactions Digoxin+amiodarone Warfarin+amiodarone
    19. 19. Prevention of Medication ErrorsPrevention of Medication Errors The Five R’sThe Five R’s Right PatientRight Patient Right DrugRight Drug Right DoseRight Dose Right RouteRight Route Right TimeRight Time
    20. 20. Principles of Good Prescribing  Use addressograph for patient details  Complete allergy box and alert label  Use generic drug names  State drug, dose, strength, route and frequency  Avoid abbreviations  Avoid multiple route prescribing (i.e. im/sc/po)  State dose as grams, mg, mcg.  Make administration of once weekly drugs clear  To amend a prescribed drug – draw a line through it, date and initial, then rewrite as new prescription.
    21. 21. Sources of Prescribing Info  Trust Prescribing Policy  BNF/eBNF  IV guides/monographs  Trust Formulary  Specialist references (e.g. Paediatric)  Summary of Product Characteristics  Pharmacist  Medicines Information  Electronic access to central library of Trust approved guidelines.
    22. 22. 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)
    23. 23. 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! Most prescribing limited to ~100 formulations (vs. >Most prescribing limited to ~100 formulations (vs. > 60,000 total)60,000 total)
    24. 24. Controlled Drugs Prescriptions  Handwritten  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.)
    25. 25. Hospital PrescribingHospital Prescribing Includes :Includes :  Evaluation of patient’s current medicationEvaluation of patient’s current medication  Selecting medication for treatmentSelecting medication for treatment - indication, formulary, licence agreements, efficacy- indication, formulary, licence agreements, efficacy  Stating considerationsStating considerations - antibiotics: duration of treatment- antibiotics: duration of treatment - warfarin: discharge dose & next INR date- warfarin: discharge dose & next INR date  Discharge medication (or TTO)Discharge medication (or TTO) = not just a rehash of the drug chart= not just a rehash of the drug chart
    26. 26. 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
    27. 27. Before Writing a Drug Chart Sources of information on current drugs  Patient  GP letter stating current medication  Repeat prescribing slip  Medical notes  Community Pharmacist  Patient’s 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?
    28. 28. Prescription/Drug Charts  ALLERGIES  BLOCK CAPITALS Approved name in BNF NOT: trade name & abbreviations  Dose, frequency and time, route  Sign entry with bleep number If in doubt check, neverIf in doubt check, never guessguess & see BNF& see BNF
    29. 29. Prescription/Drug Charts  PRN criteria:  frequency  max dose  indication Tramadol 50mg 7/11 S Jones PO qds prn. Max 200mg/24hrs
    30. 30. Specify dose  Gliclazide 80mg  Diclofenac 50mg, 75mg or 100mg?  Cipramil 10mg or 20mg?
    31. 31. Completing Drug Charts Important points  Cross –reference drugs prescribed on other charts back to the main drug chart.  Care when rewriting drug charts / transferring information to discharge summaries.  Always double check your prescription - you are legally responsible for it.
    32. 32. Parenteral Administration Chart
    33. 33. ParenteralParenteral AdministrationAdministration In some hospitals it isIn some hospitals it is part of the usual drugpart of the usual drug chartchart
    34. 34. Discharge Prescriptions  Record all drugs the patient should take even if no supplies are required on discharge.  Record drugs that have been stopped or significant changes.
    35. 35. Warfarin Chart
    36. 36. Subcutaneous Insulin
    37. 37. Insulin Chart
    38. 38. IV Medication  Check drug indications & dosages as in BNF  BNF Appendix 6: guidelines & additives  IV Monograph  Boluses and short infusions on main drug chart  Continuous IV infusions on fluid chart and cross referenced back to main drug.  KCL strong solution: now handled as CD