GOOD Prescribing

Practices
A&E Module
MBBS Year IV
2018 -19
 Objectives
 Know how to give rational treatment to a patient

 Select the appropriate drug for a patient

 Know causes of medication errors

 Know how to write a prescription

 Know how to give a patient information,

instructions and warnings about medication.
Treating a Patient
Has a systematic methodology:
• Make a rational treatment choice based on a thorough
understanding of the patho-physiology of the disease

• selecting the appropriate treatment option for the

patient.

Treatment options include :

1. advice/information
2. non-drug treatment
3. drug treatment
4. Referral for specialist care or investigation
1. Five points for Rational Rx
a)Define the diagnosis

b) Specify the therapeutic objective

c) Make an inventory of effective groups of

drugs

d) Choose an effective group according to

criteria

e) Choose a P-Drug
2.The six-step routine for selection
appropriate Rx option for patient

 Step 1: Define the patient's problem

 Step 2: Specify the therapeutic objective

 Step 3: Verify the suitability of your P-treatment

 Step 4: Start the treatment

 Step 5: Give information, instructions and warnings

 Step 6: Monitor (and stop?) treatment

Exercise Time
 Exercise scenarios
 “A man of 45 years with established mild hypertension and
no evidence of underlying primary cause or of target organ
damage, requires treatment. How would you proceed?”

 A 20 years old engineering student presents with “heart

burn” symptoms and wants treatment. How would you
proceed?

 A 35 years old man complains of a dry occasional cough for

6 months now that he wants sorted out. How would you
proceed?
 Exercise learning points
 a simple consultation of only a few minutes, in fact requires a quite complex
process of professional analysis.

 What you should not do is copy others and simply memorise what they wrote

 Instead, build your clinical practice on the core principles of choosing and giving a
treatment.
 When prescribing medication, THINK:

 What do I need to prescribe in a safe way?

 Patient information
 Co-morbid conditions

 Drug information
 Pharmacology
 Pharmacokinetics and pharmacodynamics
 Therapeutics

 Care Systems
 Policies, guidelines, prescribing aids etc
 Patient Assessment Questions
• Does the patient need this drug?
• Is this drug the most effective and safe?
• Is this dosage the most effective and safe?
• If side effects are unavoidable does the patient need
additional drug therapy for these side effects?
• Will drug administration impair safety or efficacy ?
• Are there any drug interactions ?
• Will the patient comply with prescribed regimen ?
 Taking a good medication history
 How reliable is your source – does it have enough detail?
 Patient, patient’s repeat prescription, own drugs, health passport
documentation, on-call service

 Drug details
 dose, frequency, formulation (eg modified release), start date, indication
 Include: Prescribed drugs, ‘OTC’ drugs, complementary medicines,
vitamins,
? ‘Recreational drugs’

 Allergies including severity

 Compliance

 Therapeutic failures
Factors affecting drug pharmacodynamics or
pharmacokinetics

 Children
 The elderly
 Renal impairment
 Hepatic impairment
 Prescribing in pregnancy or breast feeding
 Drug interactions
 What is an error ?
 Wrong time of
 Doses omitted
administration
 time of day
 Wrong dose  in relation to food etc....

 Unprescribed drug given  Using unstable/expired drug

 Wrong administration
 Wrong dosage form given
technique

 Wrong route of administration  Incorrect reconstitution

 Wrong rate of administration  Extra dose given

Where do errors occur in the process of
giving a drug?

 Prescribing

 Dispensing

 Administration

 Counselling/communication
 Common Prescribing Errors

 Wrong drug (e.g. drugs that sound  Calculation errors (important in

alike) Paediatrics)

 Wrong dose  Poor cross referencing

 Inappropriate Units  Infusions with not enough details of

diluent, rate etc. Poor cross-
referencing between charts
 Poor/illegible prescriptions
 Once weekly drugs
 Failure to take account of drug
interactions
 Multiple dose changes
 Omission

 Wrong route/multiple routes (IV/SC?

PO)
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

Errors ocuring during
administration
Drugs that sound alike
Clotrimazole/Co-trimoxazole
Carbamazapine/carbimazole
Risedronate/Methotrexate

Drugs that look similar in writing

ISMN / ISTIN

Inappropriate units
Insulin Mixtard 30
Dose 10 i.u. – could be read as 101 units

Drug Interactions
Digoxin+amiodarone
Warfarin+amiodarone
 Similar packaging

 Similar sounding names / similar spelling / same strength

 Ceftazidime – Cefotxime
 Similar packaging

 Same drug – several strengths

 May be colour-coded but DO NOT rely on colour
Similar Packaging
If in a hurry – These look similar
Water for injection, Sodium Chloride injection, Potassium Chloride
Prescribing responsibilities

 Drug
 Dose
 Route
 Rate of administration
 Duration of treatment

 Checking patient allergies & sensitivities

 Prescribing Responsibilities
 Providing a prescription that is:
 Legible
 Legal
 Signed
 Giving all information to allow safe administration

in a CLEAR, UNDERSTANDABLE form to:

Other doctors
Nurses
Pharmacy staff
Prescription Hints
 Clear and  Care with units
unambiguous
 Legal
 Approved name
 Is it weight/BSA-related
dosing. Is weight accurate?
 No abbreviations

 Care with IVs

Prescription Hints

 Clear decimal  Avoid abbreviations

points
0.5ml not .5ml  od / bd / tds / qds

 Rewrite charts
 Not 250mg3
regularly

 Take time, eg to
read labels
If in doubt ……..
Ask
 Prevention of Medication Errors

The Five R’s

 Right Patient

 Right Drug

 Right Dose

 Right Route

 Right Time
 Learning points:
 Accidents happen everywhere The best people make mistakes.

 Same “simple” mistake - different consequences

 Everyone is responsible for patient safety

 Writing an order is as important as making the decision what to prescribe