Safe prescribing 1 and 2 Flashcards
What is medicines reconciliation?
A process designed to ensure that all medication a patient is currently taking is correctly documented on admission and at each transfer of care (e.g. admission and discharge to and from hospital and other care settings).
Why is taking an accurate drug history an essential part of admission history taking?
An accurate drug history allows the team looking after the patient to:
– Prescribe the patients usual medication clearly and accurately on their drug chart, allowing them to continue taking their medication without delays or omissions.
– Identify any medication-related issues that might have contributed to the patients admission.
– Identify any other medication that may be needed
Steps to take… (3)
- Collecting information on the drug history using the most recent and accurate sources of information.
- Checking or verifying that list against the initial inpatient prescription, ensuring any discrepancies are accounted for and are appropriately followed up.
- Communicating the drug history together with action taken on any changes, omissions and discrepancies through appropriate documentation.
Medicines reconciliation is carried out in three stages in hospital.
- Admission
- Post admission verification (by pharmacy team)
- Discharge
Sources of information - patient.
What are the advantages?
The patient will tell you exactly how they take their medicines, which could be very different from the formal records
Sources of information - patient.
What are the disadvantages?
Patient may be confused, unable to communicate or not speak English
Sources of information - patient’s own drugs.
What are the advantages?
- Encourage patient to bring in their medication from home
- Discuss each medicine with the patient to establish how long they have been taking it and how frequently
- Do not assume that the dispensing label accurately reflect the patient usage
- Check the date of dispensing since some may bring all their medication into hospital, including those stopped.
Sources of information - patient’s own drugs.
What are the disadvantages?
Patient may leave PODs at home or they maybe old or illegible
Give an example of a compliance aid?
Dosette Boxes - these may be filled by the community pharmacist, district nurses, relatives or patient
When using a Dosette box as a source of information, what should be checked?
If dispensed by a community pharmacist, the device should be checked for dispensing labels which will provide the pharmacy contact details.
The date of dispensing should also be checked bearing in mind that the medicines may have changed.
Remember to check for “when required” medicines and medicines that may not be suitable for compliance aids such as inhalers, eye drops, once weekly tablet.
Relatives and Carers as a source of information - benefits?
Carers can be very helpful in establishing an accurate drug history and can also give an insight into how medicines are managed at home.
Relatives and Carers as a source of information - disadvantages?
Need to be mindful maintaining confidentiality
Repeat Prescriptions as a source of information - what should be checked?
Many of these repeat prescriptions may include medicines that have been stopped. The date of last issue should always be checked and each item confirmed with the patient. If there is any doubt, the GP surgery should be contacted.
GP Surgery (a faxed list) as a source of information - what should be checked?
Be aware of acute medicines, repeat medicines and past medicines on receptionists screen.
Always check when the item was last issued and the quantity issued.
Specific questioning may be needed for different formulations, inhalers, insulin devices or medicines which are brand specific (aminophylline, theophylline).
Why might the GP list be inaccurate?
Some medications are hospital only and do not appear on the usual repeat list. The GP record may be inaccurate due a recent admission.
GP Referral Letters - why are these not always reliable?
They are often written by the on-call doctor and may be illegible or incomplete.
Previous Discharge Summaries as a source of information - what should be checked?
Check whether any changes have been made by the GP since the patients previous discharge from hospital. If the patient has been home for more than two weeks it is likely that they may have visited their GP and changes made.
Discharge summaries should not be used if…?
They are more than a month old
Residential and Nursing Homes (Medication Administration Record Sheets) as a source of information - benefits?
- Useful and accurate source for a drug history
* Usually sent in with the patient
Residential and Nursing Homes (Medication Administration Record Sheets) as a source of information - when should care be taken?
Handwritten lists from homes should be used with care as they often have transcription errors.
What are Summary Care Records?
SCRs are an electronic record containing key information from the patient’s GP practice. It is optional – patients have received information through the post and can ‘opt out’ of having an SCR via their GP practice. It is only accessible with permission from the patient except for exceptional circumstances where the patient is unable to give permission e.g. unconscious or confused.
What do SCRs contain (as a minimum)?
Allergies, adverse reactions and medications
Medicine Reconciliation on Discharge - why is this important?
What should be included?
Part of the communication process with primary care is to inform the GP and patient what changes have been made to the patients medication while admission.
This means a full list of medication that should be continued post discharge should be included with the discharge letter.
Ideally reasons for stopping any medication should be included so a full picture can be gained by the primary care physicians.
Why are allergies important?
Incidents reported locally, nationally and internationally illustrate the serious harm, and in some cases fatalities that have occurred to patients who have been prescribed drugs to which they have had a pre-existing allergic response.
British National Formulary can be divided into three main sections.
- Guidance on prescribing including prescribing in palliative care and emergency treatment on poisoning.
- Chapters on individual therapeutic areas eg infections. Individual drug monographs are contained within these chapters.
- Appendices eg interactions, additives
Drug Monographs - what do these contain?
Dosing information
Details about the indication
Different doses for different licensed indications
What is gabapentin licensed for? (2)
Epilepsy and neuropathic pain
What is amitriptyline licensed for? (2)
Depression and nocturnal enuresis.
It can also be used for neuropathic pain and migraine prophylaxis (unlicensed indications).
Why do some drugs have a different dose depending on the formulation used?
Give an example.
Due to differing bioavailability
Carbamazepine suppositories: different bioavailability to the tablets or suspension.
Explain “modified release” preparations.
Give an example.
If a medicine needs to be given two or three times daily e.g. NIFEDIPINE, there will often be a modified release preparation available to allow less frequent dosing e.g. Adalat LA (once daily) and Adalat Retard (twice daily).
Oral morphine is available as immediate release preparation - how often should this be given?
Every 4 hours.
Examples of brands of morphine available as immediate release preparation (2)
Sevredol and Oramorph
Oral morphine is also available as a sustained release preparation - how often should this be given?
once or twice daily dosing
How should breakthrough pain be treated?
Where can information regarding this be found?
An additional as required (PRN) prescription of immediate release morphine
Palliative care section of BNF
How are drug interactions classified?
Pharmacodynamic OR pharmacokinetic
What is a pharmacodynamic drug interaction?
Occur when two drugs have additive or antagonistic pharmacological effects. These interactions are often
predictable.
What is a pharmacokinetic drug interaction?
Occur when a drug increases or decreases the
amount of another drug available in the body by affecting the absorption, distribution, metabolism or excretion of the other drug.
Where are drug interactions listed in the BNF?
What does a black dot mean?
Appendix 1
Considered to be the most serious interactions
Identify other sources of information about drugs (3)
Local NHS Trust Formularies
Pharmacists
The medicines information department at hospitals
Define prescribing errors.
“The result of a prescribing decision or prescribing writing process that results in an unintentional but significant reduction in the probability of treatment being timely and effective or an increased risk of harm compared with generally accepted practice”
Classify prescribing errors.
- Slips and lapses – where actions do not go according to plan e.g. intending to write 5mg of a drug but unintentionally writing 50mg
- Mistakes – where the plan itself is wrong e.g. writing 50mg of a drug not knowing the usual dose is 5mg
List the common causes of prescribing errors (7)
Inadequate knowledge of patient + their clinical status Inadequate drug knowledge Calculation errors Illegible handwriting Drug name confusion Poor history taking (Fatigue and workload)
For a prescription to be valid it needs to be…?
Signed in ink with your own name
Written in indelible (dark blue/black) ink i.e. permanent
Contain address of practitioner and appropriate date
Who takes legal responsibility for the prescription?
The signatory - hence why you need to sign legibly to legalise (full signature/bleep)
What information needs to be included for PRN medications?
– Max frequency
– Max number of doses in 24 hours
– indication
What must you always check before prescribing?
ALLERGY STATUS
What must you include on a prescription for antibiotics?
review date or course length
What is the only acceptable drug abbreviation?
GTN, otherwise NO abbreviations
How should a prescription be written?
BLOCK LETTERS, using approved names, in black/dark blue ink, with doses in full i.e. micrograms not mcg
What should you write when discontinuing a drug?
Sign/date and give reason for discontinuation
What % of prescriptions have been associated with error?
1.5%
What three different stages can errors occur?
– PRESCRIBING
– DISPENSING
– ADMINISTRATION
