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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. All matters or concerns regarding fraud or corruption should be reported to: Chris Rising, Senior Manager ([email protected] 07768 873701), Mark Trevallion, LCFS Lead ([email protected] 07800 718680) OR the National Fraud and Corruption Line 0800 028 40 60 https://www.reportnhsfraud.nhs.uk/ 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 Page 9 of 13 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 Page 11 of 13 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