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POLICY DOCUMENT
Document Title
Prescribing
Reference Number
Medicines Policy – Tab 5
Policy Type
Medicines
Electronic File/Location
http://intranep/TeamCentre/pharm/PublishedDocuments/F
orms/PolicyTabs.aspx
Intranet Location
Clinical Resources/Pharmacy/Medicines Policy
Status
Final
Version No/Date
Version 6 – September 2016
Author(s) Responsible for
Writing and Monitoring
Lead Pharmacist Mid
Approved By and Date
Medicines Management Group September 2016
Implementation Date
October 2016
Review Date
September 2019
© North Essex Partnership University NHS
Copyright
Foundation Trust (2016). All rights reserved. Not to
be reproduced in whole or in part without the permission of
the copyright owner.
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IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 1 of 13
Contents
Section
Page
Number
Topic
5.1
Introduction
3
5.2
Aim
3
5.3
Scope
3
5.4
Reference to other standards, policies or procedures
3
5.5
Prescribing for inpatients
4
5.6
Prescribing for short leave or discharge
6
5.7
Prescribing for outpatients
6
5.8
Unlicensed and off-label use of medicines
7
5.9
Formulary
8
5.11
Summary of changes
8
1
Form A – Formulary request
9
2
Form B – Non-formulary medication use request
11
3
Form C – Outcome report following Form B Approval
13
Appendices
Compliance Monitoring
Compliance with this procedure will be against the Trust’s agreed minimum requirement/standard
as detailed within the Auditable Standards and Monitoring Arrangements
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 2 of 13
Prescribing
5.1.
INTRODUCTION
5.1.1. Prescribing of medicines to patients is a common treatment intervention. The
correct and safe prescribing of medicines leads to the correct and safe
administration of medicines and ultimately a safe, positive patient experience and
outcome.
5.1.2. Where prescribing occurs outside of recognised standards and guidelines, there is a
greater risk of error and patient harm. Prescribers should not prescribe
beyond/outside their competence.
5.2.
AIM
5.2.1. To provide guidance on prescribing for inpatients and outpatients that ensures safe
prescribing and administration of medicines.
5.3.
SCOPE
5.3.1. This policy applies to all prescribers for NEP inpatients and outpatients and any NEP
staff involved in monitoring adherence to this policy such as registered nursing and
pharmacy staff. For non-medication prescribing please refer to Tab 5a on the
IntraNEP
5.4.
REFERENCES TO OTHER STANDARDS, POLICIES OR PROCEDURES
 NEP Medicines Policy Tab 17 – High risk medicines
 NEP Medicines Policy Tab 13 - Clozapine
 NEP Medicines Policy Tab 19 – PRN Prescribing
 NEP Prescribing and Treatment Guidelines – High dose antipsychotics
 NEP Prescribing and Treatment Guidelines – inpatient alcohol detox
 NEP Medicines Policy Tab 10 – Controlled Drugs
 NEP Prescribing and Treatment Guidelines – Nutritional Supplements
 NEP Prescribing and Treatment Guidelines – Traffic Lights (formulary)
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 3 of 13
5.5.
PRESCRIBING FOR INPATIENTS
5.5.1. All prescriptions for inpatients should be written on the inpatient Prescription and
Medication Administration Chart (PMAC) or an approved supplementary chart such
as for Clozapine or Warfarin.
5.5.2. All demographic and personal details on the front of the PMAC should be completed
by the prescriber but some sections can be completed by nursing or pharmacy staff if
missing (MHA status, weight, height, BMI, allergy status, ward, consultant)
5.5.3. The prescriber must adhere to the following prescribing standards:
 All sections of the drug chart (PMAC) to be completed

Write in black, indelible ink in block capitals

Drugs to be prescribed using approved name only unless it is a brand-specific
medicine (eg lithium)

Times should be specified using a 24 hour clock format eg 13:00 for 1pm

All prescriptions should specify a dose

All prescriptions should be for one route only ie ‘PO’ and ‘IM’ require two
prescriptions and cannot be written as ‘PO/IM’

All prescriptions must be signed and dated with the prescribers name printed
after the signature

Review dates should be stated where required

Antimicrobial prescriptions should state the indication and duration

No amendments can be made to prescriptions; it should be crossed off with a
single line through the prescription and on the administration section, signed
and dated

Decimal points should be avoided where possible eg 500 micrograms instead
of 0.5mg

The form should be stated where a specific form is to be given eg liquid for a
prescription specifying the route as oral

Liquids should always specify the strength of the preparation, the dose and
volume in ml to be given

Micrograms and units should always be written in full, never abbreviated
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 4 of 13

‘When required’ (prn) prescriptions must all state a dose, dosing
interval/maximum dose in 24 hours and an indication for use (see PRN Policy
for further information.

An allergy status must always be documented in the following format:
drug/drug group the patient as an allergy/sensitivity to, nature of reaction eg
‘Penicillin – whole body rash’
5.5.4. Prescribers should refer to the high risk medicines policy (tab 17) for further advice
on prescribing anticoagulants, insulin, cytotoxic preparations and others.
5.5.5. Prescribers should refer to the clozapine policy (tab 13) for guidance and
requirements for prescribing clozapine.
5.5.6. When prescribing antipsychotics, prescribers should ensure that the maximum dose,
including prn use, for a single or multiple combined antipsychotics doesn’t go above
100% of the BNF recommended maximum. This requires additional monitoring and
the completion of high dose antipsychotic treatment documentation – see
prescribing and treatment guidelines for more information.
5.5.7. Prescribers must ensure the correct section of the PMAC is used for specific items as
follows:
 Variable dose section – chlordiazepoxide reducing regime for alcohol
withdrawal

Long acting injections section – antipsychotic depot injections,
hydroxycobalamin

Once only section – loading/test doses of antipsychotic depot injections.
Note – for remote prescription or direction to administer (aka verbal order),
please refer to Tab 1 Standards for Medicines Management.
5.5.8. When prescribing controlled drugs, if a supply is required labelled for an individual
patient, a controlled drug prescription must be completed by the prescriber – see
controlled drugs policy (tab 10) for further information.
5.5.9. Nutritional supplements should be prescribed by a dietician on the PMAC following
the NEP Nutritional Supplements Formulary. However, if a dietician is unable to see
the patient in a suitable time frame, NEP prescribers may prescribe nutritional
supplements for inpatient use pending a review by the dietician.
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 5 of 13
5.6.
PRESCRIBING FOR SHORT LEAVE OR DISCHARGE
5.6.1. Pharmacy staff will ensure that inpatients have sufficient supply of regular
medication for use on the ward. Where there is no risk, this supply can also be used
for short leave and discharge – please refer to the One Stop Dispensing Policy for
further information (tab 14).
5.6.2. For short leave, the prescriber should complete the short leave section on the
reverse of the PMAC to specify how many days’ medication is required and which, if
any, when required medicines are to be supplied. This is only necessary if the patient
is an overdose risk requiring a specific quantity of medication.
5.6.3. For discharge, a 24 hour discharge form should be completed, listing any changes in
medication during admission and the current medication on discharge. The
prescriber should also complete the self-harm risk assessment to identify any
patients at risk of overdose and therefore requiring a limited quantity of medication
on discharge. Where there is no risk, up to a month of medication (minimum of two
weeks) can be supplied without the doctor specifying a quantity on the discharge
form. Nursing staff will endorse the quantity given when checking medication prior
to discharge.
5.7.
PRESCRIBING FOR OUTPATIENTS
5.7.1. The majority of community teams prescribe medication on FP10s for patients to
obtain supply in the community. For use of FP10s, please refer to Tab 5b of the
Medicines Policy.
5.7.2. Prescriptions should be written for new or amended medicines where an immediate
change is required. No more than one month’s supply should be prescribed unless
there is a valid reason for prescribing more eg shared/continuing care guidelines
where no interim monitoring is required (please see specific guidelines for more
information).
5.7.3. Prescribing should only be for the treatment of mental illness. Prescribing for any
other conditions should be referred back to the GP.
5.7.4. Where FP10s are not used, a NEP outpatient prescription should be used and faxed
to Pharmacy for supply. These are available from Pharmacy. An NEP outpatient
prescription should only be used when it is possible to order the medication from
Pharmacy in advance.
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 6 of 13
5.8.
UNLICENSED AND OFF-LABEL USE OF MEDICINES
5.8.1. The use of unlicensed and off-label medicines is common in psychiatry.
5.8.2. An unlicensed medicine is a medicine without a UK market authorisation (product
license). An off-label medicine is a medicine with a UK market authorisation being
used for an indication for which it does not hold a UK market authorisation.
5.8.3. The AD for Pharmacy takes responsibility for the quality of any unlicensed medicines
purchased for NEP use. A certificate of analysis can be requested from Pharmacy if
necessary.
5.8.4. A list of unlicensed medicines stocked by NEP Pharmacy is available on request from
the Pharmacy Department. This list should be approved by the Medicines procedures
Group and Medicines Management Group (MMG).
5.8.5. If a Consultant wishes to use an unlicensed medicine not on the approved list, a nonformulary request (Form B – see below) should be submitted to the MMG.
5.8.6. As per the GMC, before prescribing an unlicensed medicine the must prescriber
must:
 Be satisfied there is sufficient evidence or experience of using the medicine to
demonstrate its safety and efficacy
 Take responsibility for prescribing the medicine and for overseeing the patient’s
care, monitoring, and any follow up treatment, or ensure that arrangements are
made for another suitable doctor to do so
 Make a clear, accurate and legible record of all medicines prescribed and, where
you are not following common practice, your reasons for prescribing an
unlicensed medicine
5.8.7. When prescribing any unlicensed or off-label medicine, the prescriber must ensure
consideration is given to the ability for the patient to continue this medication postdischarge if necessary. There should be a discussion with the GP as the GP is not
obliged to continue to prescribe an unlicensed medicine. Where a GP is not willing to
prescribe but the Consultant wants the patient to continue, the NEP prescriber
should continue to prescribe as necessary.
5.8.8. The patient and their family should be informed where possible of unlicensed and
off-label prescribing.
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 7 of 13
5.8.9. Where a licensed product is available, every effort should be made to use the
licensed product.
5.9.
FORMULARY
5.9.1. Prescribing of psychotropic medicines should follow the NEP Formulary (traffic lights)
available on the IntraNEP under Prescribing and Treatment Guidelines.
5.9.2. A consultant can request the addition of a specific medication to the formulary by
completing Form A (Appendix 1) and submitting to the MMG.
5.9.3. If a consultant wishes to use a medication that is non-formulary, a Form B (Appendix
2) should be submitted to the MMG for approval.
5.9.4. For the prescribing of physical health medicines, the local CCG formulary should be
adhered to.
5.9.5. If a patient is admitted from primary care already taking a non-formulary medication,
this can be continued without the requirement for a Form B, but should be reviewed
within the first week of admission to determine its appropriateness.
5.9.6. Where a Form B is approved, the Consultant who made the request may be asked to
provide feedback to the MMG via Form C (Appendix 2). This may then be used to
consider a formulary application.
12.1
SUMMARY OF CHANGES
Date
September
2016
Section
Number(s)
All
Summary of Changes
Full re-write
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 8 of 13
Appendix 1 – Form A
Medication Request for Inclusion on the Trust Formulary
All requests should be discussed with Pharmacy before application
Please send the completed form to the Associate Director for Pharmacy
The request will be discussed at the next MMG and forwarded to the CCGs who would also need to
approve its place in their formularies.
Applicant Details
Name of Consultant:
Main contact telephone number:
Email address:
Signature and date:
Declaration of conflict of interest (state specifics or ‘none to declare’)
Medication Details
Non-proprietary (generic) name:
Manufacturer:
Dosage form (ie tablet, ampoule, liquid etc) and
strength:
Pack size:
Cost:
Please indicate source of cost information:
BNF / Drug representative / Hospital pharmacy
Pharmacology and Indications
Licensed indication(s):
Indication being requested (if different):
Intended place in therapy (eg first line, second
line, specific patient group only etc):
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
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Brief description of mode of action:
Safety Profile
Main adverse effects:
Contra-indications:
Significant interactions:
Prescribing and Monitoring
Dosage proposed for this application:
Monitoring for proposed use (including
criteria for stopping treatment):
Reason(s) for Request
List existing preparations currently
included on the Trust formulary for the
same indication:
State claimed advantage(s) over the
above preparations:
Please provide evidence to support the application and details stated above. This should be in the
form of published clinical trials and any national recommendations eg NICE. Copies of papers will
need to be provided. Please state references below:
Date of discussion at MMG:
Outcome (tick):
Trust approval (forward to CCGs)
More information required
Rejected (provide reasons to applicant)
Adapted with thanks to NEMMC December 2015, revised September 2016
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 10 of 13
Appendix 2 – Form B
Request for use of a non-formulary medication for a named patient
Please complete this form to provide reasons for requesting use of a non-formulary product. Provide
as much detail as possible to prevent delays in being able to process the request. Where medication
is requested for an inpatient and is to continue on discharge, the patient’s community team
Consultant should also provide their support to the application.
All requests should be sent to the Associate Director for Pharmacy.
Requests will be discussed at the Trust MMG.
Applicant Details
Name of Consultant:
Main contact telephone number:
Email address:
Signature and date:
Patient Details
Patient name:
NHS Number:
Ward / unit:
Medication Details
Non-proprietary (generic) name:
Dosage form (ie tablet, ampoule, liquid
etc) and strength:
Proposed indication:
Proposed dosage:
Cost:
Please indicate source of cost information:
BNF / Drug representative / Hospital Pharmacy
Reason(s) for Request
Current medication:
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
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Other medication used without
success:
State proposed benefit from using
non-formulary medication:
Please state and provide any additional information and/or references to support this request:
Community Team Approval (if required)
Name of Consultant:
Community Team:
Main contact telephone number:
Email address:
Signature and date:
Outcome
Date of discussion at MMG:
Outcome (tick):
Approved
Approved with conditions (state)
More information required
Rejected (provide reasons to applicant)
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 12 of 13
Appendix 3 – Form C
Outcome report following approval for use of a non-formulary medication
Following approval of a Form B, the MMG may request feedback on the response of the patient to
the treatment. This form is used to gather that feedback.
Medication and Patient Details
Name of patient receiving non-formulary
medication:
NHS Number:
Ward / unit:
Medication approved via Form B (include
dose, route, strength and form):
Date medication started:
Outcome Report
Please comment on patient
concordance to treatment:
Please comment on efficacy:
Please comment on any adverse
effects:
Please provide any additional feedback:
Is treatment to continue:
Report Completed by:
Name and job role:
Contact telephone and email address:
Tel.
Email:
Sign and date:
MMG Review
Date of MMG Review:
Further feedback to be requested (by when):
To be consider for inclusion in formulary:
Yes / No
Date for feedback:
Yes / No
IntraNEP / Clinical resources / Pharmacy / Medicines Policy / Tab 5
Tab 5
Implementation Date: October 2016
Review Date: October 2019
Page 13 of 13