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