Title: Prescribing Getting It Right the First Time
1Prescribing (Getting It Right the First Time)
Yolinda Haarhoff Pharmacist Teacher
Practitioner Cambridge Graduate Course for
Medicine (e-mailYolinda.Haarhoff_at_wsh.nhs.uk)
2Objectives
- Importance of Teaching Prescribing
- Why do errors occur?
- Practical prescribing advice
- Different drug charts
- Examples of common errors
3- 25 July 2000
- 113 dead
- Entire world in shock
4Deadly 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 gt1 in 10 pts
1/3 of these are serious
In 8 of these cases, it lead to the patients
death
5To Err Is Human
The Audit Commission A spoonful of sugar -
medicine management in NHS hospitals
- Core cirricula 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
6To Err Is Human Why Teach Prescribing?
- Errors more likely when new Drs arrive in
Hospital - Audit Commission a Spoonful of
sugar - Continuing education in prescribing technique
required for new doctors
- Irish medical Journal
7Medication Errors and Reducing Risk JHO
Prescribing OSCE
- Average achievement 58
- If 70 was required only 5 would pass
- Difficulties
- Drug allergies interactions
- Writing a CD prescription
- Unfamiliar with BNF
8Human Aspects of Errors
- Impedance of Performance
- - Fatigue Sleep deprivation
- - Hunger Long lapses between food/drink
- - Concentration Lapses
- - Stress Loss of control/cutting corners
- - Other factors Alcohol, drugs illness
9Spot the difference?
Look alike drugs contribute to medication errors
10Spot the difference?
Look alike drugs contribute to medication errors
11Spot the difference?
Look alike drugs contribute to medication errors
12- Administering the wrong drug could be fatal
- NHS standard
- Water
- Sodium chloride
- Lignocaine
13Error Prevention
- The Five Rs
- Right Patient
- Right Drug
- Right Dose
- Right Route
- Right Time
14Prescribing Protection
Your Best New Friend!
BNF
- Reference source for prescribing
- If uncertain, look it up - ALWAYS
- Use in conjunction with trusts medication
policy formulary
15BNF 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)
16Formularies 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! - Personal formularies can be useful
Most prescribing limited to 100 formulations
(vs. gt 60,000 total)
17Legal Aspects Governing Prescribing
- Medicine Act 1968
- Poisons Act 1972
- Misuse of Drugs Act 1971
Regulates ALL retail and wholesale dealings in
medicine
18The Prescription
Should state - what is to be given to whom and
- by whom prescribed, and give instructions
on - how much should be taken how often, - by
what route and for how long or total quantity
supplied
19Controlled Drugs Prescriptions
- Handwritten requirements
- 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.)
BNF p7
20Hospital Prescribing
- Includes
- Evaluation of patients current medication
- Selecting medication for treatment - indication,
formulary, licence agreements, efficacy - Stating considerations - antibiotics duration
of treatment - - warfarin discharge dose next INR date
- Discharge medication (or TTO) not just a
rehash of the drug chart
21Before 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
22Before Writing a Drug Chart
- Sources of information
- GP letter stating current medication
- Patients 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?
23Prescription/Drug Charts
- ALLERGIES
- BLOCK CAPITALSApproved name in BNFNOT trade
name abbreviations - Dose, frequency, route
- Sign entry with bleep number
If in doubt check, never guess see BNF
24Drug Name Abbreviations
- NO!!! ALWAYS Avoid
- ISMN prescribed, patient got Istin
- BNF
25Prescription/Drug Charts
CYCLIZINE 50mg 7/11 S Jones
PO Nausea 150mg/24h
- PRN criteria
- frequency
- max dose
- indication
26Completing Drug Charts Important points
- Care when rewriting drug charts / transferring
information to discharge summaries - Never guess doses - always check the BNF
- Always double check your prescription you are
legally responsible for it
27Example
28Completing a Prescription Chart
- Mickey Mouse has been admitted to your ward and
you have to compete his drug chart from the GP
repeat slip - Atenolol 25mg od
- Diclofenac 50mg tds
- GTN spray prn
- The decision has been made to start with
- 1) IV antibiotic therapy and the drug of choice
is cefuroxime 1g tds - 2) Paracetamol prn for pain
- Other information available states that he is
penicillin allergic and weighs 60kg
29(No Transcript)
30Parenteral Administration Chart
31Parenteral Administration In some hospitals it is
part of the usual drug chart
32TTO or TTA (To Take Out)
33Warfarin Chart
34(No Transcript)
35Subcutaneous Insulin
36Insulin Chart
37FP10
- Hospital Community
- Various colours
38Drug Calculations
- Strength you want Strength
you've got it in
x
amount required
Volume youve got it in
Watch out for Pharmaceutical preparations -
suppositories - liquids to tablets or vice versa
39IV Medication
- Check Drug indications dosages as in BNF
- BNF Appendix 6 guidelines additives
- To be written on Drug Chart NOT Fluid Chart
- ? Trust IV handbook ?
- KCL strong solution now handled as CD
40PrescribingWhere Do Errors Occur?
- Prescribing process - completing drug chart
transcription from GP note / Pts own medicine
- re-writing the drug chart - writing the TTO -
insufficient discharge information - Dispensing process - illegible writing
- Administration of medication - illegible writing
on drug chart - unclear instructions
41Transcription Error
42Methotrexate Folic Acid
43Allergies Interactions
44Incomplete Drug Chart
45Never Abbreviate
- Micrograms
- Units or iuTinzaparin 3500u
46TTOs Lack of Information
- Discharge information needs to be improved to
prevent prescribing errors - Better training for HOs needed in completing
TTOs
- Pharmaceutical Journal Jan 2002
47Dose Error
48Specify dose
- Gliclazide 80mg
- Diclofenac50mg, 75mg or 100mg?
- Cipramil10mg or 20mg?
49GP Based Review of TTO Errors
- Total TTOs 268 28 errorsgt1 error/TTO
- Other findings - poor communication - changes
in therapy not communicated
Northumbria Healthcare Trust
50(No Transcript)
51Drug ChartTTO
52Incomplete TTO
53Incomplete TTO
54Completing a TTO
The decision is made to discharge Mr Henderson.
In addition to the drugs on his chart, the
pharmacist left you a green note indicating all
the other drugs that have been missed off. Can
you complete the TTO?
- Other drugs on this chart
- Ranitidine 150mg twice a day
- Allopurinol 100mg once daily
- Nicorandil 20mg once daily
- Aspirin 75mg once daily
- Sando K one twice daily
- GTN spray when required
55Transcription Error
56Bioavailability differences
No date or sig.
57Poor Handwriting Leading to Dispensing Error
58Poor Handwriting Leading to Dispensing Error
59Poor Handwriting Abbreviations
60TTO for the day
- STOP
- THINK
- ASK
- LISTEN
- LOOK
Its Your Responsibility!