Prescribing

Question 1

When is it safe to prescribe?

Answer 1

You should only prescribe medicines if you have adequate knowledge of the patient’s health and you are satisfied that the medicines serve the patient’s needs.
You must consider:
- the suitability of the mode of consultation (e.g. face-to-face, remote), taking into account any need for physical examination or other assessments
- whether you have sufficient information to prescribe safely, e.g. if you have access to their medical records
- whether you can establish two-way dialogue, make an adequate assessment of the patient’s needs and obtain consent.
- whether you can share information appropriately after an episode of care.

Question 2

When are face-to-face consultations more appropriate than remote consultations?

Answer 2

• You are unsure of the patient’s capacity to decide about treatment
• You need to physically examine the patient
• You are not the patient’s usual doctor and they have not given you consent to share their information with their regular prescriber; this is particularly important if the treatment needs following up or monitoring or you are prescribing medications where additional safeguards are needed
• You are concerned that a patient does not have a safe and confidential place to access healthcare remotely, e.g. due to domestic abuse
• You are concerned that a patient may be unable to make a decision freely as they’re under pressure from others

Question 3

What should you do if you are not the patient’s regular prescriber?

Answer 3

Introduce yourself to the patient, telling them your name, role, and GMC number
Outline the consultation agenda and encourage them to raise questions/concerns.
You should ask for the patient’s consent to contact their GP or other treating Doctors if you need more information or confirmation of the information you have before prescribing, and to share information with their GP when the episode of care is completed.
If the patient objects to information being shared with you, or does not have a regular prescriber, you must be able to justify a decision to prescribe without that information.
If the patient refuses to consent to you sharing information with their GP, or does not have a GP, you should explain to the patient the risks of not sharing this information. This should be
documented in their medical records. If failing to share information could pose a risk to patient safety, you should explain to the patient that you cannot prescribe. You should outline their options and signpost them to appropriate alternative services. You should clearly document your reasons for any decisions made.
If you have consent to share information with the patient’s GP, you should tell the GP any changes to the patient’s medicines along with reasons, including if existing medicines are
changed or stopped, and new medicines are started, the length of intended treatment, monitoring requirements, including who will
carry this out, and any new allergies or adverse reactions identified.

Question 4

How do you judge if you have enough information about a patient to prescribe medication for them?

Answer 4

You must only prescribe if it safe to do so.
It’s not safe if you don’t have sufficient information about the patient’s health or if the mode of consultation is unsuitable for their needs. It may also be unsafe if relevant information is not shared with other healthcare providers involved in the patient’s care, i.e. because the patient refuses consent.
Before prescribing, you must consider whether the information you have is sufficient and reliable enough to enable you to prescribe safely e.g. whether you have access to their medical records, you can verify other important information by examination/testing, the pt would be at risk of death or serious harm if they are also obtaining medication from other sources.

Question 5

Why is establishing a dialogue important for prescribing?

Answer 5

It helps them to consider information about their options so they can decide whether or not to have treatment. Good dialogue should give both you and your patient the opportunity to ask questions to get the information you both need.
If it’s not possible to clarify or ask for more information from the patient in the environment you are working, you should consider whether it is safe to prescribe, and raise concerns as
appropriate. For example, it may be appropriate to raise concerns if the system in which you’re working involves prescribing remotely on the basis of a questionnaire and there is no mechanism for two-way dialogue or communication with patients.

Question 6

How do you ensure you give patients sufficient information to make an informed decision about their treatment?

Answer 6

You should reach an agreement with the patient on the proposed treatment, explaining the likely benefits, risks and impact, including common and serious side effects, what to do in the event of a side effect or recurrence, how and when to take the medication and how to adjust the dose if necessary, how to use the medical device, the likely duration of treatment, and any relevant arrangements for monitoring, follow-up and review, further consultation, blood tests, processes for adjusting the type or dose of medicine and for issuing repeat prescriptions.

Question 7

Can medication be prescribed without consent?

Answer 7

Yes, if it is likely to be of overall benefit to patients who lack capacity, or in accordance with mental health legislation.

Question 8

What are other effective ways of giving information to patients about their medication?

Answer 8

Pharmacists can undertake medication reviews, explain how to take medication and offer advice on interactions and side effects
PILs are useful supplements to the information you give to patients about their medicines
With the patient’s consent, you should provide patients’ carers with information about the medicines you prescribe (if the pt lacks capacity to consent, you should share this info with carers where it would be of overall benefit to the patient)

Question 9

What are other effective ways of giving information to patients about their medication?

Answer 9

Pharmacists can undertake medication reviews, explain how to take medication and offer advice on interactions and side effects
PILs are useful supplements to the information you give to patients about their medicines
With the patient’s consent, you should provide patients’ carers with information about the medicines you prescribe (if the pt lacks capacity to consent, you should share this info with carers where it would be of overall benefit to the patient)

Question 10

How should you respond to medication requests from patients which will not benefit them?

Answer 10

Explore their reasons for their request
Explore their understanding of what it would involve and their expectations of the outcome
If, after discussion, you still think the treatment would not be beneficial, you should not prescribe it. Explain why, and explore other options that might be available, including their right to seek a second opinion.

Question 11

What should a patient’s GP be informed of upon discharge?

Answer 11

• changes to the patient’s medicines along with reasons, including if existing medicines are changed or stopped, and new medicines are started
• length of intended treatment
• monitoring requirements, including who will carry this out
• any new allergies or adverse reactions
  identified.

Question 12

When would privacy concerns override the need to share information?

Answer 12

In some circumstances, such as the use of sexual health services, privacy may be instilled to a higher degree. This
means that your personal details and any information about the tests or treatments you have received will not be shared with anyone outside the sexual health service without your permission. This includes your GP.

Question 13

How should you approach a patient who is not taking medication as prescribed?

Answer 13

• Try to understand the reasons for this
• Address any concerns, provide reassurance and useful information
• Try to reach an agreement with the patient on an appropriate course of treatment that they are able and willing to adhere to.

Question 14

What are the principles surrounding controlled drugs and medications with additional safeguards?

Answer 14

Some categories of medicine may pose
particular risks of serious harm or may be associated with overuse, misuse or addiction. When prescribing, you should follow relevant clinical guidance, such as drug safety updates on the risk of dependence and addiction associated with opioids.
If you don’t have access to relevant information from the patient’s medical records you must not prescribe controlled drugs or medicines that are liable to abuse, overuse or misuse or
when there is a risk of addiction and monitoring is important. Exceptions to this are when no other person with access to that information is available to prescribe without unsafe delay and it is necessary to avoid serious deterioration in health or to ensure continuity of treatment where a patient is unexpectedly without access to medication for a limited period.
In this situations, you should provide a limited quantity and dose until they’re able to see an appropriate clinician with access to their medical records or you are able to verify that information yourself.
Also consider the possibility that the patient may be obtaining meds from other sources.
You will also be required to share information with the patient’s GP with their consent.
You should give the patient the names, roles and contact details of key people who will be involved in their care, as well as advice about who they can contact if they have any questions
or concerns. This is particularly important if you are prescribing remotely.

Question 15

Can you prescribe controlled drugs to yourself or someone close to you?

Answer 15

No, unless it will avoid serious deterioration in health or avoid
serious harm or will ensure continuity of treatment where a patient is unexpectedly without access to
medication for a limited period or there is no other person with the legal right to prescribe available to assess and prescribe without a delay.

Question 16

Can you prescribe medicines for your own convenience or for the convenience of others?

Answer 16

You must not prescribe medicines for your own convenience or the convenience of other health or social care professionals (for example,
prescribing sedatives for the convenience of those caring for patients with dementia in care
homes where there is no clinical justification.

Question 17

What are the principles around prescribing for yourself or those close to you?

Answer 17

Wherever possible, you must avoid prescribing for yourself or anyone you have a close personal relationship with.
If you prescribe any medicine for yourself or someone close to you, you must make a clear record at the same time or soon as possible afterwards; the record should include your relationship to the patient, where relevant, and the reason it was necessary for you to prescribe.
Must ensure it is safe to prescribe and that the patient consents for you to share the information with their GP.

Question 18

What should you do if you’re prescribing remotely to a patient in a care-home/nursing home/hospice?

Answer 18

You should communicate with the patient, or if that’s not practicable, the person caring for them, to make
your assessment and to provide the necessary information and advice. You should make sure any instructions, such as how to administer the drug or monitor the patient’s condition, are understood. And you should send written confirmation to them as soon as possible.

Question 19

What are the principles surround prescribing at the recommendation of a colleague?

Answer 19

You should be satisfied that the prescription is needed, appropriate for the patient, and within the limits of your competence.
If you delegate the assessment of a patient’s suitability for a medicine, you must be satisfied that the person you delegate to has the qualifications, experience, knowledge, and skills to make the assessment. Give them enough information about the patient to carry out the assessment.
You will ultimately be responsible for any prescription you sign.

Question 20

What should you do if you’re uncertain about your competence to take responsibility for the patient’s continuing care?

Answer 20

You should ask for further information/advice from the clinician who is sharing care responsibilities or from another experienced colleague. If you’re still not satisfied, explain this to the other clinician and to the patient, and make appropriate arrangements for their continuing care.

Question 21

What should you do if you have concerns about prescribing by other colleagues?

Answer 21

You must protect patients from risks of harm posed by colleagues’ prescribing (i.e. cross off, date and sign an incorrect prescription, actively stop a patient from taking a wrong prescription if you witness it).
Question any decision or action that you consider may be unsafe
Respond constructively to concerns raised by colleagues/patients/carers about your own practice.
Make patient safety your first priority and raise concerns if the service/system does not have adequate safeguards

Question 22

Why is it important to report adverse reactions/incidents/near misses involving medicines and devices?

Answer 22

Early, routine reporting can ensure performance and systems issues are investigated, problems rectified and lessons learned.
You must use the Yellow Card Scheme to inform the MHRA about serious suspected adverse reactions to a medication, and any suspected adverse reactions to products marked with a Black Triangle symbol.
Adverse incidents involving medical devices, including those caused by human error, that put, or have the potential to put, the safety of
patients, healthcare professionals or others at risk must be reported to the medical device safety lead in your organisation (if there is one)
and the relevant national body, e.g. the MHRA.

Question 23

Who should you report patient safety incidents to?

Answer 23

• National Reporting and Learning System (NRLS)
• The patient’s GP, the pharmacy that supplied the medicine, the local controlled drugs accountable officer and the medicine manufacturers.

Question 24

What are the principles around reviewing medicines?

Answer 24

Whether you prescribe with repeats or on a one-off basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review. You should take account of the patients’ needs and any risks arising from the medicines.

Question 25

What are the principles surrounding repeat prescriptions?

Answer 25

You must make sure that any repeat prescription you sign is safe and appropriate.
You should consider the benefits
of prescribing with repeats, and where possible, reduce repeat prescribing.
Make it clear to the patient why regular reviews are important and explain what to do if they suffer side effects/adverse reactions, stop taking the medicine before the agreed review date.
Must be satisfied the right patient is issued with the right prescription, the correct dose is prescribed, the patient’s condition is monitored, any medication changes are quickly reviewed and incorporated into their record.
Consider whether requests for repeats earlier/later than expected may indicate poor adherence.
When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient

Question 26

What are unlicensed medications?

Answer 26

Medicines which are used outside the terms of their UK licence or that have no licence for use in the UK.

Question 27

When is prescribing unlicensed medicines necessary?

Answer 27

• There is no suitably licensed medicine that can meet the patient’s needs e.g. there is no licensed medicine for a child who needs medication only licensed for adults would meet the child’s needs, the dosage specified for a licensed medicine would not meet the patient’s need, the patient needs a medicine in a formulation that is not specified in an applicable licence.
• a suitably licensed medicine that would meet the patient’s need is not available, e.g. due to temporary shortage in supply.
• the prescribing forms part of an approved research project
• there is a serious risk to public health and the MHRA has temporarily authorised the sale/supply of an unlicensed medicine e.g. a vaccine

Question 28

What information should you give to patients about the licence of their medication?

Answer 28

You must give patients, or their parents or carers, sufficient information about the medicines you propose to prescribe, to allow them to make an informed decision.
Some medicines are routinely used outside the terms of their licence, for example in treating children. In emergencies or where there is no realistic alternative treatment and such information is likely to cause distress, it may not be practical or necessary to draw attention to the licence. In other cases, where prescribing unlicensed medicines is supported by authoritative
clinical guidance, it may be sufficient to describe in general terms why the medicine is not licensed for the proposed use or patient population.
You must always answer questions from patients, or their parents or carers, about medicines fully and honestly.
If you intend to prescribe unlicensed medicines where it’s not routine or if there are suitably licensed alternatives available, you should explain this to the patient, and give your reasons for
doing so.