Prescribing Safely
Narinder Bhalla
Lead Pharmacist – Clinical Governance
Addenbrooke’s NHS Trust
March 2005
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
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)
When it goes wrong
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
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
Definition of Medication Incident/Error
A medication error is “A preventable prescribing, dispensing, drug
Administration or clinical advice (relating to drugs) error.”
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
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
Spot the difference?
Look alike drugs contribute to medication errors
Spot the difference?
Look alike drugs contribute to medication errors
Spot the difference?
Look alike drugs contribute to medication errors
Lidocaine
Administering the wrong drug could be fatal“NHS standard”:
Water Sodium
chloride Lidocaine
(lignocaine)
Examples
Drugs that sound alikeClotrimazole/Co-trimoxazole
Carbamazapine/carbimazole
Risedronate/Methotrexate
Drugs that look similar in writingISMN / ISTIN
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 Prescriptions
Month and date
19/12
20/12
21/12
22/12
23/12
24/12
25/12
26/12
27/12
28/12
29/12
30/12
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.
Opioids
Not always bioequivalent by different routese.g. IM Morphine 10mg = 2.5-5mg IV
Codeine Not given IV, the only licensed parentral route is IM
DihydrocodeineNot given IV, appropriate parentral routes are SC or IM.
If codeine or dihydrocodeine given IV, 100% bioavailability thereforedanger of respiratory depression and other opioid side-effects.
Slow- release/Non- slow release formulationsMST/SevredolOxycontin/Oxynorm
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.
Examples
Inappropriate unitsInsulin Mixtard 30 Dose 10 i.u. – could be read as 101 units
Drug InteractionsDigoxin+amiodaroneWarfarin+amiodarone
Prevention of Medication ErrorsPrevention of Medication Errors
The Five R’sThe Five R’s� Right PatientRight Patient� Right DrugRight Drug� Right DoseRight Dose� Right Route Right Route � Right TimeRight Time
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.
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.
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)
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)
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.)
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
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
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?
Prescription/Drug Charts
ALLERGIES BLOCK CAPITALS
Approved name in BNFNOT: trade name & abbreviations
Dose, frequency and time, route
Sign entry with bleep number
If in doubt check, never If in doubt check, never guessguess & see BNF & see BNF
Prescription/Drug Charts
PRN criteria: frequency max dose indication
Tramadol 50mg
7/11 S Jones PO
qds prn.
Max 200mg/24hrs
Specify dose
Gliclazide 80mg Diclofenac
50mg, 75mg or 100mg?
Cipramil10mg or 20mg?
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.
Parenteral Administration Chart
Parenteral Parenteral AdministrationAdministrationIn some hospitals it is In some hospitals it is part of the usual drug part of the usual drug chartchart
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.
Warfarin Chart
Subcutaneous Insulin
Insulin Chart
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