Download Responsibilities of the prescriber

An Introduction to
Prescribing
Narinder Bhalla
Lead Pharmacist – Clinical Governance
Addenbrooke’s NHS Trust
November 2006
Objectives
 What is prescribing?
 Responsibilities of the prescriber
 Good prescribing principles
 Using the BNF and other info sources
 Principles of prescribing in special groups
When it goes wrong
What is prescribing
Writing/generation of a prescription for a drug (paper
or electronic).
Verbal order for a drug to be administered on doctor’s
advice.
Responsibilities of the prescriber
 If you prescribe a drug you are clinically and legally
responsible for your actions.
 If you are asked to prescribe the drug, it is the person
who signs the prescription who is responsible
Responsibilities of the prescriber
Right Patient
 Right Drug
 Right Dose
 Right Route
 Right Time

Responsibilities of the prescriber

Only prescribe medicines that you are competent to prescribe.
(knowledge of drug indication, action, dosing, side-effects,
interactions).
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Only prescribe medicines if they are necessary
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Prescribe only if benefits of medication outweigh the risks

Discuss treatment options with the patients/concordance

Indicate likely/degree of benefit (efficacy), onset and duration
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Discuss side-effects/tolerability
Concordance
(www.medicinespartnership.org)
 The prescriber and the patient should agree on the
health outcomes and the strategy for achieving
them.
 Consider religious, cultural and personal beliefs
that may affect acceptance of medicines.
 Keep drug regimes simple and review regularly
 Combination treatments only if benefits outweigh
risks (restrict ability to titrate doses).
Principles of Good Prescribing
 State patient details clearly (name, address, date of birth, age
(children/elderly).
 Take account of any allergies and complete relevant paperwork.
 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
Generic Prescribing
 Prescribe by the approved drug name
 Ensures clarity regarding drug required
 Ensures that the most-cost effective version of the drug
can be supplied.
Commonly Used latin abbreviations
ac.
bd.
od.
om. on.
tds
tid
pc.
prn
qds
- ante cibum (before food)
- bis die (twice daily)
- omne die (once daily)
-omni mane (every morning)
- omni nocte (every night)
- ter die sumendus (to be taken three times daily
- ter in die (three times daily)
- post cibum (after food)
- pro re nata (when required)
- quarter die sumendus (to be taken four
times daily
Types of prescription
 FP10 (white)
Standard NHS prescription issued by GPs that can
be dispensed by a pharmacy registered to
dispense NHS prescriptions
 FP10(HP) Yellow
NHS prescription issued by hospitals, that can be
dispensed by a registered pharmacy.
 FP10P
Nurse prescriber’s NHS prescriptions that can be
dispensed by a registered pharmacy.
Types of prescription
 Hospital prescriptions
Outpatient clinic prescriptions
Main drug chart
Anticoagulant chart
Diabetic chart
IV chart
Factors affecting prescribing
 Patient’s clinical state
 Concomitant disease
 Severity of current disease
 Available treatments
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(consider likely outcomes (patient oriented
outcomes)/quality of life).
Likely efficacy of treatments
Side-effects/tolerability
Interactions (drugs and food)
Compliance/health benefits
British National Formulary (BNF)
www.bnf.org
 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
 Abbreviations used in the BNF (BNF Back page)
BNF (www.bnf.org)
The main text consists of classified notes on clinical conditions, drugs and preparations.
These notes are divided into 15 chapters, each of which is related to a particular system
of the body or to an aspect of medical care.
Chapter 1: Gastrointestinal system
Chapter 2: Cardiovascular system
Chapter 3: Respiratory system
Chapter 4: Central Nervous System
Chapter 5: Infections
Chapter 6: Endocrine system
Chatper 7: Obs and Gynae and Urinary tract disorders
Chapter 8: Malignant disease and immunosuppression
Chapter 9: Nutrition and blood
Chapter 10: Musculoskeletal and joint disorders
Chapter 11: Eye
Chapter 12: ENT
Chapter 13: Skin
Chapter 14: immunological products and vaccines
Chapter 15: Anaesthesia
Drug listings in the BNF
Drug Name
Indications:
(details of use and indications)
Cautions: details of precautions required (with cross-references to appropriate
Appendixes) and also any monitoring required.
Contra-indications: details of any contra- indications to use of the drug.
Side-effects: details of common and more serious side-effects.
Dose: dose and frequency of administration (max dose); Child and Elderly
details of
dose for specific age group.
By alternative route, dose and frequency.
Approved name: form, pack size and price.
Proprietary name: form, pack size and price.
BNF Appendixes
Appendix 1-Drug Interactions
 A black dot symbol is placed against those interactions
that are potentially hazardous.
 Interactions listed by drug/drug class in alphabetical
order.
BNF Appendixes
Appendix 2
 Table of drugs to be avoided or used with caution in liver
disease
Appendix 3
 Principles of dose adjustment in renal impairment
 GFR values
 Table of drugs to be avoided or used with caution in
renal impairment
BNF Appendixes
Appendixes 4 and 5
 Prescribing in pregnancy and breast feeding
Appendix 6
Intravenous additives
 Table of common drugs given IV and how to
prepare, dilute and administer them.
Yellow Card Reporting
Doctors, nurses, pharmacists and patients may
complete a yellow card report
Report
1. All suspected reactions to new medicines (black triangle)
2. All serious suspected reactions to established medicines
3. Report all serious and minor reactions in children (<18yrs).
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.
Prescribing for children
 Children are not little adults
 Many drugs not licensed for use in children
 Use a specialist children's formulary “BNF for Children”.
 Weights and occasionally surface areas are required
to calculate accurate doses. These parameters may
change significantly in a relatively small time period.
Prescribing for Children
 Pharmacokinetic changes in childhood are important and
have a significant influence on drug handling.
 The availability of a product does not ensure its
suitability for use in children.
Prescribing for the Elderly
 18% of the population are over 65yrs age.
 Receive 1/3 of NHS prescriptions
 Absorption, metabolism, distribution and elimination of
drugs affected by ageing.
 Renal function deteriorates with age.
 Alzheimer’s disease, dementia and other cognitive
disorders, Parkinson's disease are important disorders in
the elderly.
 Drugs such as NSAIDS, opioids, benzodiazepines etc
are likely to cause problems in the elderly.
Prescribing for the Elderly
Principles of prescribing
 Avoid unnecessary drug therapy
 Effect of treatment on quality of life
 Treat the cause rather than the symptom
 Drug history
 Concomitant medical illness
 Choice of drug
 Dose titration
 Dosage form
 Packaging and labelling
 Good record keeping
 Regular review
Formularies & ‘Essential’ Drugs
 National formularies (e.g. the BNF)
provide an independent source of advice.
 Hospital formularies reflect hospital choices, based on evidence
based and cost-effective evaluation of the evidence base for a drug.
 WHO provide a ‘model’ list of essential drugs (~300 items).
Common Prescribing Errors
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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