Safe prescribing 1 and 2

Question 1

What is medicines reconciliation?

Answer 1

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).

Question 2

Why is taking an accurate drug history an essential part of admission history taking?

Answer 2

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

Question 3

Steps to take… (3)

Answer 3

1. Collecting information on the drug history using the most recent and accurate sources of information.
2. Checking or verifying that list against the initial inpatient prescription, ensuring any discrepancies are accounted for and are appropriately followed up.
3. Communicating the drug history together with action taken on any changes, omissions and discrepancies through appropriate documentation.

Question 4

Medicines reconciliation is carried out in three stages in hospital.

Answer 4

1. Admission
2. Post admission verification (by pharmacy team)
3. Discharge

Question 5

Sources of information - patient.

What are the advantages?

Answer 5

The patient will tell you exactly how they take their medicines, which could be very different from the formal records

Question 6

Sources of information - patient.

What are the disadvantages?

Answer 6

Patient may be confused, unable to communicate or not speak English

Question 7

Sources of information - patient’s own drugs.

What are the advantages?

Answer 7

• 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.

Question 8

Sources of information - patient’s own drugs.

What are the disadvantages?

Answer 8

Patient may leave PODs at home or they maybe old or illegible

Question 9

Give an example of a compliance aid?

Answer 9

Dosette Boxes - these may be filled by the community pharmacist, district nurses, relatives or patient

Question 10

When using a Dosette box as a source of information, what should be checked?

Answer 10

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.

Question 11

Relatives and Carers as a source of information - benefits?

Answer 11

Carers can be very helpful in establishing an accurate drug history and can also give an insight into how medicines are managed at home.

Question 12

Relatives and Carers as a source of information - disadvantages?

Answer 12

Need to be mindful maintaining confidentiality

Question 13

Repeat Prescriptions as a source of information - what should be checked?

Answer 13

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.

Question 14

GP Surgery (a faxed list) as a source of information - what should be checked?

Answer 14

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).

Question 15

Why might the GP list be inaccurate?

Answer 15

Some medications are hospital only and do not appear on the usual repeat list. The GP record may be inaccurate due a recent admission.

Question 16

GP Referral Letters - why are these not always reliable?

Answer 16

They are often written by the on-call doctor and may be illegible or incomplete.

Question 17

Previous Discharge Summaries as a source of information - what should be checked?

Answer 17

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.

Question 18

Discharge summaries should not be used if…?

Answer 18

They are more than a month old

Question 19

Residential and Nursing Homes (Medication Administration Record Sheets) as a source of information - benefits?

Answer 19

• Useful and accurate source for a drug history

* Usually sent in with the patient

Question 20

Residential and Nursing Homes (Medication Administration Record Sheets) as a source of information - when should care be taken?

Answer 20

Handwritten lists from homes should be used with care as they often have transcription errors.

Question 21

What are Summary Care Records?

Answer 21

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.

Question 22

What do SCRs contain (as a minimum)?

Answer 22

Allergies, adverse reactions and medications

Question 23

Medicine Reconciliation on Discharge - why is this important?
What should be included?

Answer 23

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.

Question 24

Why are allergies important?

Answer 24

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.

Question 25

British National Formulary can be divided into three main sections.

Answer 25

• 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

Question 26

Drug Monographs - what do these contain?

Answer 26

Dosing information
Details about the indication
Different doses for different licensed indications

Question 27

What is gabapentin licensed for? (2)

Answer 27

Epilepsy and neuropathic pain

Question 28

What is amitriptyline licensed for? (2)

Answer 28

Depression and nocturnal enuresis.

It can also be used for neuropathic pain and migraine prophylaxis (unlicensed indications).

Question 29

Why do some drugs have a different dose depending on the formulation used?
Give an example.

Answer 29

Due to differing bioavailability

Carbamazepine suppositories: different bioavailability to the tablets or suspension.

Question 30

Explain “modified release” preparations.

Give an example.

Answer 30

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).

Question 31

Oral morphine is available as immediate release preparation - how often should this be given?

Answer 31

Every 4 hours.

Question 32

Examples of brands of morphine available as immediate release preparation (2)

Answer 32

Sevredol and Oramorph

Question 33

Oral morphine is also available as a sustained release preparation - how often should this be given?

Answer 33

once or twice daily dosing

Question 34

How should breakthrough pain be treated?

Where can information regarding this be found?

Answer 34

An additional as required (PRN) prescription of immediate release morphine
Palliative care section of BNF

Question 35

How are drug interactions classified?

Answer 35

Pharmacodynamic OR pharmacokinetic

Question 36

What is a pharmacodynamic drug interaction?

Answer 36

Occur when two drugs have additive or antagonistic pharmacological effects. These interactions are often
predictable.

Question 37

What is a pharmacokinetic drug interaction?

Answer 37

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.

Question 38

Where are drug interactions listed in the BNF?

What does a black dot mean?

Answer 38

Appendix 1

Considered to be the most serious interactions

Question 39

Identify other sources of information about drugs (3)

Answer 39

Local NHS Trust Formularies
Pharmacists
The medicines information department at hospitals

Question 40

Define prescribing errors.

Answer 40

“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”

Question 41

Classify prescribing errors.

Answer 41

1. Slips and lapses – where actions do not go according to plan e.g. intending to write 5mg of a drug but unintentionally writing 50mg
2. Mistakes – where the plan itself is wrong e.g. writing 50mg of a drug not knowing the usual dose is 5mg

Question 42

List the common causes of prescribing errors (7)

Answer 42

Inadequate knowledge of patient + their clinical status
Inadequate drug knowledge
Calculation errors
Illegible handwriting
Drug name confusion
Poor history taking
(Fatigue and workload)

Question 43

For a prescription to be valid it needs to be…?

Answer 43

Signed in ink with your own name
Written in indelible (dark blue/black) ink i.e. permanent
Contain address of practitioner and appropriate date

Question 44

Who takes legal responsibility for the prescription?

Answer 44

The signatory - hence why you need to sign legibly to legalise (full signature/bleep)

Question 45

What information needs to be included for PRN medications?

Answer 45

– Max frequency
– Max number of doses in 24 hours
– indication

Question 46

What must you always check before prescribing?

Answer 46

ALLERGY STATUS

Question 47

What must you include on a prescription for antibiotics?

Answer 47

review date or course length

Question 48

What is the only acceptable drug abbreviation?

Answer 48

GTN, otherwise NO abbreviations

Question 49

How should a prescription be written?

Answer 49

BLOCK LETTERS, using approved names, in black/dark blue ink, with doses in full i.e. micrograms not mcg

Question 50

What should you write when discontinuing a drug?

Answer 50

Sign/date and give reason for discontinuation

Question 51

What % of prescriptions have been associated with error?

Answer 51

1.5%

Question 52

What three different stages can errors occur?

Answer 52

– PRESCRIBING
– DISPENSING
– ADMINISTRATION