Medication Incidents& safe prescribing

FY2 (part 2 of 2)

2016

Over View

• Case studies and prescribing (40 min)

• Golden tips on safe prescribing (10 min)

Case ONE: Mr Green

Mr Green (1111222) 72 year old male, Admitted to MFE ward with SOB and a productive cough.

PMHx High cholesterol, OA, Parkinson’s disease

DHx: see next slide, NoK has a bag of drugs

Allergies: Penicillin, Doxycycline• O2 sats: 82% OA

• Scattered wheezes heard on auscultation.

• Temp: 38.2.

• WBC 17.2, CRP 113.

• U+E N (Urea 5mmol/l)

• RR: 18

• BP: 121/71

∆ ?CA-LRTI In the mean time write up Mr Greens drug chart

Daily

2 QDS prn

1 on

1 TDS

1 min

• NO Metoclopramide

• Parkinsonspatient

Regular Prescriptions 2

Date

Circle times or enter other times

26/9

4. Drug (approved name)

Rotigotine Start Date

26/9/14

06 08

Dose

6mg/24hrs

Route

Top(Patch)

Frequency

Once daily

12

14 Reason for starting / stopping

Parkinsons Disease

Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

5. Drug (approved name)

Simvastatin

Start Date

26/9/14

06 08

Dose

40mg

Route

po

Frequency

Once Daily

12

14 Reason for starting / stopping

High cholesterol

Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18 22

Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

6. Drug (approved name) Start Date 06 As Required Prescriptions 1

1. Drug (approved name)

Sodium Chloride 0.9% Start Date

On admission Date/

Time

Dose

5 mL Route

IV Pharm:

STOCK Route

Maximum Frequency

See Trust Protocol To flush peripheral cannula, flushes for

other types of IV line must be prescribed. Dose

Prescriber’s Signature

As per Trust Drug Protocol 1.2

Given By

2. Drug (approved name)

Co-dydramol 10/500

Start Date

26/9/14

Date/

Time

Dose

Ii

Route

po

Pharm: cc: DH New

STOCK/ POD / TTO / IP / CD Route

Maximum Frequency

qds

Indication / Other Instructions

pain Dose

Prescriber’s Signature

Hbassi Bleep No

1287

Given By

3. Drug (approved name)

Start Date Date/

Time

As Required Prescriptions 1

1. Drug (approved name)

Sodium Chloride 0.9% Start Date

On admission Date/

Time

Dose

5 mL Route

IV Pharm:

STOCK Route

Maximum Frequency

See Trust Protocol To flush peripheral cannula, flushes for

other types of IV line must be prescribed. Dose

Prescriber’s Signature

As per Trust Drug Protocol 1.2

Given By

2. Drug (approved name)

Co-dydramol 10/500

Start Date

26/9/14

Date/

Time

Dose

Ii

Route

po

Pharm: cc: DH New

STOCK/ POD / TTO / IP / CD Route

Maximum Frequency

qds

Indication / Other Instructions

pain Dose

Prescriber’s Signature

Hbassi Bleep No

1287

Given By

3. Drug (approved name)

Start Date Date/

Time

What is Mr Green’s CURB score?

Age>65years

CURB score of 1

Prescribe antibiotic(s)

1 min

How many opted for:Amoxicillin

Clarithromycin

Doxycycline

Co-amoxiclav

Tazocin

Community Acquired Pneumonia

Mod severity

Antibiotic policy recommends

Amoxicillin 500mg tds po

plus

clarithromycin 500mg bd po 7 days

Penicillin allergy:

Doxycycline 200mg po stat then 100mg-200mg od 7 days

Antibiotics Only Review IV route daily

Antibiotics Only Review IV route daily

Antibiotic Prescriptions 1 Indication and stop or review date MUST be completed by prescriber

On review consider if IV route necessary refer to Trust policy for further guidance

Date Circle times or enter other times

1. Antibiotic (approved name)

Clarithromycin Start Date

26/9/14

06 08

Dose

500mg

Route

po

12

14 Frequency/Other Instructions

Twice daily

Supply

POD ( ) TTO /IP/Stock/Fridge

Sign: Date:

18

22 Indication(s)

LRTI

cc Date

DHx New

24

Prescriber’s Signature

HBassi Bleep No

1287

Initial Stop /Review Date

5/7

Revised Stop/Review Date Revised Stop/Review Date Revised Stop/Review Date

4. Drug (approved name)

Simvastatin

Start Date

26/9/14

06 08

Dose

40mg

Route

po

Frequency

Once Daily

12

14 Reason for starting / stopping

High cholesterol

Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18 22 X X X X X

Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx

New

24

Hold while co-prescribed Macrolide (clarithromycin) 5. Drug (approved name) Start Date 06

Regular Prescriptions 2

7/7

Xx/xx/xx

Xx/xx/xx

Case Two: Mrs Brown

Mrs Brown (55667789) admitted to A&E with confusion 2° to UTI, now successfully being treated with Trimethoprim 200mg BD 5/7. Her vitals are currently stable

PMHx: CCF, High cholesterol, OA (will not take Bisposponates)

DHx: see bag of drugs

Allergies: NKDA

The cases is handed over to you, as the FY2 to write up her drug chart.

Mrs Brown takes all of

these tablets once a

day

Regular Prescriptions 2

Date Circle times or enter other times

26/9

4. Drug (approved name)

Adcal D3 Start Date

26/9/14

06 08

Dose

One

Route

po

Frequency

Once daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

5. Drug (approved name)

Digoxin

Start Date

26/9/14

06 08

Dose

250micrograms

Route

po

Frequency

Once Daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

6. Drug (approved name)

Simvastatin

Start Date

26/9/14

06 08

Dose

40mg

Route

Po

Frequency

Once daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

7. Drug (approved name) Start Date 06

Xx/xx/xx

Xx/xx/xx

Duplication

• Simvastatin and Bezafibrate both given for hypercholerstolaemia

• High risk drug? No

• Acute indication? No

• Confirm with a second source (Medicines reconciliation)

Medicines reconciliation

• Pharmacist confirms that Bezafibrate was stopped and replaced with Statin.

• All of the other tablets are correct however Mrs Brown was started on the following by her GP last month Amlodipine 10mg OD

Regular Prescriptions 2

Date Circle times or enter other times

26/9

4. Drug (approved name)

Adcal D3 Start Date

26/9/14

06 08

Dose

One

Route

po

Frequency

Once daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

5. Drug (approved name)

Digoxin

Start Date

26/9/14

06 08

Dose

250micrograms

Route

po

Frequency

Once Daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

6. Drug (approved name)

Simvastatin

Start Date

26/9/14

06 08

Dose

40mg

Route

Po

Frequency

Once daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

7. Drug (approved name)

Simvastatin

Start Date

26/9/14

06 08

Dose

20mg

Route

Po

Frequency

Once daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx

New 24

8. Drug (approved name)

Amlodipine

Start Date

26/9/14

06 08

Dose

10mg

Route

Po

Frequency

Once daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx

New

24

9. Drug (approved name) Start Date 06

STOP dose reduced due to interaction with amlodipine. HBassi #1287

26/9/14

Xx/xx

Xx/xx

Xx/xx

Xx/xx

Xx/xx

MHRA guidance Drug interactions associated with increased risk of myopathy/rhabdomyolysis

Interacting agents Prescribing recommendationsItraconazoleKetoconazolePosaconazoleErythromycinClarithromycinTelithromycinHIV protease inhibitors (eg, nelfinavir)NefazodoneCiclosporinDanazolGemfibrozil

Contraindicated with simvastatin

Other fibrates (except fenofibrate) Do not exceed 10 mg simvastatin dailyAmiodaroneAmlodipineVerapamilDiltiazem

Do not exceed 20 mg simvastatin daily

Fusidic acidPatients should be closely monitored. Temporary suspension of simvastatin treatment may be considered.

Grapefruit juice Avoid grapefruit juice when taking simvastatin

Case Three: Mrs Pink

You are on-call and asked to see Mrs Pink (22335544).

She was admitted to EAUS for a planned TKR however unsuitable for surgery, her BP has been dropping since admission. Currently 87/58mmHg

Unable to access her EMPA drug chart

Nurse informs

you patient is

currently

prescribed One

of each…..

-Amiodarone

100mg od

-Amlodipine

10mg od

-Atenolol 75mg

od

-as per her bag

of drugs

Don’t assume.• Confirm atenolol dose.

– 25mg

– 50mg

– 75mg?

• Amiodarone and atenolol interaction (negative chronotropic ) thus confirm the dose!

• Even with electronic prescribing we INPUT into the system. Errors are two fold now:

– System errors (EMPA/drug charts/ICE)

– User errors (us lot)

Pharmacist confirms

following 3 drugs…… all ONCE daily

Regular Prescriptions 2

Date Circle times or enter other times

26/9

4. Drug (approved name)

Atenolol Start Date

26/9/14

06 08

Dose

25mg Route

po

Frequency

Once daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

5. Drug (approved name)

Amiodarone Start Date

26/9/14

06 08

Dose

100mg

Route

po

Frequency

Once Daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

6. Drug (approved name)

amlodipine Start Date

26/9/14

06 08

Dose

10mg

Route

Po

Frequency

Once daily

12

14 Reason for starting / stopping Supply

POD ( ) TTO /IP/Stock/CD /Fridge

Sign: Date:

18

22 Prescriber’s Signature

HBassi

Bleep No

1287

cc Date

DHx New

24

7. Drug (approved name)

Simvastatin

Start Date

26/9/14

06

Xx/xx/xx

Xx/xx/xx

Xx/xx/xx

Can you see a

potential error here?

Electronic systems –

alphabetised – reading

in a rush

Case Four: Mrs Blue

• Admitted to AMU-L via ambulance.

• See clinical notes

• You are asked to write up the drug chart for this lady

• Mr Blue has documented Mrs Blue’s acute past medical history and Drug history in a letter

Drug name Form Dose frequency

Drug Husbands List TTO GP list

Buprenorphine - - Yes

Candesartan Yes Yes Yes

Lercandipine 20mg od Yes Yes Yes

Simvastatin Yes Yes Yes

Adcal d3 Yes Yes Yes

Aspirin Yes Yes Yes

Atenolol Yes Yes Yes

Bendro Yes Yes Yes

Moxonidine - Yes -

Alendronic acid - Yes -

Drug Husbands List Old TTO 2012 GP list

Buprenorphine Check patient - Yes

Candesartan Yes Yes Yes

Lercandipine 20mg od Yes Yes Yes

Simvastatin Yes Yes Yes

Adcal d3 Yes Yes Yes

Aspirin Yes Yes Yes

Atenolol Yes Yes Yes

Bendro Yes Yes Yes

Moxonidine STOP - Yes -

Alendronic acid STOP - Yes -

Case Five: Mrs Yellow

You are a GP and one of your regular patients, Mrs Yellow (2/8/1962, 13 mountain way, any town, NM90KL) comes to see you for a regular prescription.

PHx: Chronic back pain, depression

DHx: Morphine Sulphate MR 20mg BD, Citalopram 10mg OD

Allergies: NKDA

You are keen to control her pain but monitor her progress regularly so write a 2/52 repeat prescription

BNFZomorph® (Archimedes)

Capsules , m/r, morphine sulfate10 mg (yellow/clear enclosing pale yellow pellets),

net price 60-cap pack = £3.47; 30 mg (pink/clear enclosing pale yellow pellets),

60-cap pack = £8.30; 60 mg (orange/clear enclosing pale yellow pellets),

60-cap pack = £16.20; 100 mg (white/clear enclosing pale yellow pellets),

60-cap pack = £21.80; 200 mg (clear enclosing pale yellow pellets), 60-cap

pack = £43.60. Label: 2, counselling, see belowDose every 12 hours, dose adjusted according to

daily morphine requirements; for further advice on determining doses, see Prescribing in Palliative

Care; dosage requirements should be reviewed if the brand is altered

2/8/1962 Mrs Yellow

13 mountain way,

Any town, NM90KL

Please supply

Citalopram 10mg OD x 1op

Morphine Sulphate

Modified release Capsules

20mg Twice daily,

total supply of (Fifty six) 56 x 10mg capsules

/////

Hbassi x/y/zz

Not an error – but

slows down patients

receiving drugs

Checking in the BNF

Easier – call the

pharmacy and check

stock/strengths

available

Revision of common Pall care

agents and doses

• Nausea & Vomiting – Haloperidol 2.5-10mg/24hrs

– Cyclizine 150mg/24hrs

– Metoclopramide 30-120mg/24hrs

– Levomepromazine 6.25-25mg/24hrs

• Anxiety/aggitation– Midazolam 10-60mg/24hrs

– Haloperidol 10-30mg/24hrs

– Levomepromazine 25-200mg/24hrs

• Pain – Diamorphine patient specific doses

– Morphine – patient specific doses

– Alfentanyl – patient specific doses

• Respiratory secretions– Hyoscine hydrobromide 600mcg-2.4mg/24hrs

What is Safe

prescribing?

What are the two common causes for prescribing errors?

• Time pressure• Prescribing in isolation

Resilience• Recognise triggers

• Rushed

• New drugs• Someone breathing down your neck• High risk drugs• Time sensitive drugs Slow down & double check

High risk drugs

• Methotrexate

• Anticoagulants

• Injectable medicines

• Epidurals

• Oral chemotherapy

• Oral opiates

• Medical gases

• Insulin

• Parkinsons

Drugs with time-sensitivity

• Anticoagulants, antiplatelets, thrombolytics

• Antiepileptics

• Anti-parkinsonians

• Anti-diabetics (insulin & oral hypoglycaemics)

• Antimicrobials (systemic routes only)

• Steroids

• Immunosuppressants

• Chemotherapy & associated adjunctive therapy

• Electrolyte correcting agents

• Anti-arrhythmics

• Anti-anginal agents

Thank you for listening ….Any questions?