Safe Prescribing & ADME Flashcards
What are the different codes for prescribing according to method of delivery?
IM = intramuscular IV = intravenous PO = oral PR = per rectum SC = subcutaneous SL = sublingual IT = intrathecal SR = slow release
What is the first step of the checklist for avoiding medication error?
Consider the patient
i.e. young or elderly, pregnant, etc.
What is the second step of the checklist for avoiding medication error?
Correct chart & correct patient?
Check patient name, D.O.B., & hospital no.
What is the third step of the checklist for avoiding medication error?
Diagnosis/therapeutic aim
Correctly identified underlying disorder?
What is the fourth step of the checklist for avoiding medication error?
Right drug for patient
- avoid therapeutic duplication e.g. paracetamol + co-codamol
- any serious drug-drug interactions (cause treatment failure or ADRs)
- any allergy to agent/group of agents (note antibiotics that contain penicillin but do not end in -illin)
- drug name spelt correctly/not open to misinterpretation
- no drug abbreviations
- form of drug is correct (e.g. liquid for children/dysphagia) AND change the dose & freq. to reflect this
What is the fifth step of the checklist for avoiding medication error?
Illness effect on distribution/elimination?
HRH, obesity
What is the sixth step of the checklist for avoiding medication error?
Alternatives to choice of drug?
- efficacy & safety
- cost
- non-drug options
- alternatives in BNF
What is the seventh step of the checklist for avoiding medication error?
Non-prescription medication interactions
e.g. St. John’s Wort (antidepressant)
What is the eighth step of the checklist for avoiding medication errors?
Route of administration
e.g. oral antibiotics preferred to IV, insulin absorption differs depending on route of administration
What is the ninth step of the checklist for avoiding medication error?
Correct dose
- doses can vary between GP & hospital
- doses can vary according to indication
- risk of ADRs increases with dose
- ?modify in HRH impairment & body weight extremes
- DECIMAL POINT ERRORS!!!!
- CONFUSION BETWEEN UNITS!!!! (use g & mg but write out micrograms & nanograms)
What is the tenth step of the checklist for avoiding medication error?
Correct frequency/timing
- timing relevant to meals can be important (esp. for lipid-soluble drugs)
- appropriate timings e.g. diuretics in the morning to avoid nocturia
- some drugs are prescribed weekly (ensure not prescribed daily)
What is the eleventh step of the checklist for avoiding medication error?
Duration of therapy
- how long will it be required?
- when will the treatment be stopped and what will determine this?
What is the twelfth step of the checklist for avoiding medication error?
ADRs
Most frequent & most serious
What is the thirteenth step of the checklist for avoiding medication error?
Drug/therapeutic monitoring required?
If so, what observations will indicate that the therapeutic aim has been achieved (by when and by whom)
What is the fourteenth step of the checklist for avoiding medication error?
Information/explanation to patient
How much info does the patient require for the therapy to be successful? Compliance?
What is the fifteenth step of the checklist for avoiding medication error?
Special prescribing requirements
e.g. controlled drug prescriptions require total quantity in words and figures on TTO
What are some rules to follow when writing prescriptions to avoid misunderstandings?
Use generic names of drugs (unless instructed by BNF)
Avoid abbreviations
Some doses depend on body weight (g/kg) but only up to a point (max. dose allowed)
TTO (to take out) - write total quantity of controlled drugs in words and figures
Amend electronic record if incorrect to prevent repeat prescription prescribing errors
What are some patient factors which cause prescribing errors?
- rapid throughput of patients
- new drug developments
- increasing complexity & specialisation
- sicker & older patients = more vulnerable to ADRs due to co-morbidities (e.g. HRH impairment), multiple drugs, etc.
What are some pharmaceutical factors causing prescribing errors?
- clinical evidence for drug efficacy & safety based on relatively healthy patients & volunteers
- some ADRs only discovered during post-marketing surveillance
What are some doctor factors causing prescribing errors?
- expected to be perfect on first day of practice
- medical education on prescribing differs
- fatigue/hypoglycaemia/hypovolaemia
- shift work/reduced hours (lower exposure to teaching, working alone, less ward teaching & feedback, poorer morale, lack of continuity of care)
- on call (rarely know patients, routine jobs e.g. re-writing drug charts, prescribing fluids, prescribing unfamiliar drugs, prescribing old drugs in absence of results)
Define an error. What are the different types of error in Reason’s framework of accident causation?
ERROR = failure of a planned sequence of actions to achieve desired goal because an adequate plan was incorrectly executed (skill-based slips or memory-based lapses) OR because an inadequate plan was made (rule-based or knowledge-based mistakes)
- slips = actions in which there are recognition or selection failures (“whoops”)
- lapses = failure of memory or attention
- mistakes = incorrect choice of objective, or choice of an incorrect path to achieve it (rule-based or knowledge-based)
What is a violation in Reason’s framework of accident causation?
VIOLATION = instances in which rules of correct behaviour are consciously ignored
What are the different codes for prescribing according to time of day?
mane = morning nocte = night
What are the factors at the level of individual responsibility for failure?
LATENT CONDITIONS = organisational process and management decisions
e.g. staffing levels, culture, poor education/training, handwritten prescriptions
ERROR-PRODUCING CONDITIONS = environment, team, individual, or task factors that affect performance
- environment = busy ward, interruptions
- team = lack of supervision
- individual = limited knowledge
- task = repetitive, poor chart design
Defences e.g. pharmacists checking prescriptions