Edition No: 2.1 ID Number: POLCMM008 Dated: June 2015 Review Date: February 2019 Document ID: Guidelines Document Type: Corporate Directorate: Clinical Support Medicines Category: Services Management Department(s): Pharmacy Author/Reviewer: Chief Pharmacist Sponsor: Medical Director Policy Dissemination Intranet Consultation Process Name of Individuals Consulted Name of Specialised Committee / Group Consulted Medicines Management Committee Corporate Approval & Ratification Committee Title Medicines Management Committee Date: May 2015 Committee Title Policy Review Group Date: June 2015 Document Control / History Edition Reason for change No 1 Required review 2 Review with no major changes 2.1 Extended review date to enable full review Document References: Ref No Trust Associated Documents: Medicines Management Policy POLCPCM033 Medway NHS Foundation Trust [2015] Edition No: 2.1 Page 1
Table of Contents 1 Introduction... 3 2 Roles and responsibilities... 3 2 Prescribing Standards and Guidance... 3 3 Other notes on using Prescription Charts... 9 4 Monitoring and Review... 9 5 Equality Impact Assessment Statement & Tool Appendix 1... 10 6 Guidance for patients admitted on chemotherapy, cytotoxic or immunosuppressant treatment - Appendix 2.11 Edition No: 2.1 Page 2
1 Introduction 1.1 Prescribing and administration errors are a significant risk to patient safety. If a prescription is written clearly and unambiguously the chances of a medication error occurring are reduced. Prescribing should never be done in a rush. 1.2 Although electronic prescribing can substantially reduce the risk of certain types of prescribing error, and eliminate legibility issues, it carries its own risks of error. The Trust aspires to introduce electronic prescribing and this is currently under review. 2 Roles and responsibilities 2.1 It is the responsibility of all prescribers to be aware and adhere to this policy 2 Prescribing Standards and Guidance General Good practice principles Prescribers must ensure that they are familiar with the medicine and its indication and that the dose, frequency, route of administration and duration of treatment are appropriate Unclear or incomplete prescriptions may result in delayed or omitted doses, or in the patient receiving the wrong medication. Always check the allergy/ drug sensitivity box before prescribing anything. Only one prescription chart should be used per patient at a time unless one chart or section becomes full.. If two charts are needed they must be fastened together with a treasury tag and clearly labeled on the front of each chart that there are two charts (i.e. 1of 2 and 2 of 2 ). Patient details ALL drug charts, discharge prescriptions and out-patient prescriptions must show the patient s name, Hospital number, NHS number and consultant. A patient ID label may be used (though see also the CD policy section 5.8 as for CD s these must be signed by the prescriber). Drug charts and discharge prescriptions must also show the correct location. Allergies and Drug sensitivities. The weight will vary in paediatric patients, so a recent or clinically appropriate weight should be used, if necessary discuss with the responsible clinician. Any adult prescription where dosing is weight dependent (e.g. low molecular weight heparins, chemotherapy) must also show a recent weight. This includes discharge prescriptions. Weights should be recorded on the drug chart The allergy box must be completed, even if the patient has no history of drug allergy or sensitivity, when it should be endorsed No Known Drug Allergies. Where there is a positive history of allergy or sensitivity, details of the reaction as well as the drug should also be Edition No: 2.1 Page 3
recorded. It should be made clear if the patient has an allergy or sensitivity. If the patient has a medical condition which means they may be intolerant to some drugs, it is useful to make a note of this e.g. Caution G6DP deficiency. Drug Write clearly. All prescriptions must be legible, unambiguous and correctly spelt. The generic name of the medicine should be used, unless there are significant differences in bioavailability between brands, where switching brands would pose a therapeutic risk (e.g. ciclosporin, tacrolimus). Insulin and Biosimilars should be prescribed by brand name. Any prescription which is illegible, unclear or ambiguous must be re-written, preferably by the original prescriber; medication must not be administered until this action is complete. For oral liquids, the strength of the liquid preparation being used should be specified. Start Date All prescriptions need a start date to be legally valid. All prescriptions must be dated when written. If the prescriber does not wish administration to begin yet, it should be post-dated with the appropriate date and the preceding dates on the drug chart crossed through. Nurses may not administer medication against a prescription with no start date. When a prescription is re-written, the date should be that on which the drug was first given on the current admission, NOT the date the chart was re-written Dosage Quantities of one gram or more should be written in grams e.g. 1.2g, not 1200mg. Quantities less than one gram should be written in milligrams e.g. 800mg not 0.8g. Quantities less than one milligram should be written in micrograms e.g. 250 micrograms, not 0.25mg. Quantities less than one microgram should be written in nanograms e.g. 250 nanograms, not 0.25 micrograms. Do NOT use trailing zeroes e.g. 5mg not 5.0mg, which can be misread as 50mg. Where a decimal is unavoidable e.g. expressing a percentage, a leading zero must be used e.g. 0.5%, not.5%, which can be misread as 5%. Doses for liquid preparations should ideally be written in g/mg/micrograms rather than milliliters. This reduces the risk of dose error where more than one strength of liquid is available. The strength of liquid in use should still be stated. Dose units mg is an acceptable abbreviation for milligrams. g is an acceptable abbreviation for grams ml or mls are acceptable abbreviations for millilitres; cc or cm3 are not acceptable. Micrograms must be written in full; mcg or g are not acceptable. Nanograms must be written in full. Edition No: 2.1 Page 4
Units must be written in full; IU or U is not acceptable. Frequency An administration frequency must be specified on the drug chart for all regular prescriptions. Although the use of Latin and other common abbreviations is still common practice, the use of directions in plain English is to be encouraged ( every 4 hours in preference to q4h, qqh or 4 ) All PRN prescriptions must state a minimum dose interval ( 4 hours, not 4 times daily ) and, if necessary, a maximum frequency. PRN alone is not acceptable. Administration times Appropriate administration times must be indicated on the drug chart by the prescriber; without these a nurse cannot administer medication.when selecting administration times, consideration should be given to the time the patient usually takes their medication, the timing of usual medication rounds on the ward, when the drug needs to be taken with respect to food, and side-effects such as drowsiness or Signature and bleep number insomnia. All prescriptions must be signed by the prescriber, in indelible ink, and should include an extension or bleep number so that they can be contacted if there are any queries about the prescription. Indication A specific indication, or at the very least a working diagnosis, must be included for all antimicrobials. An indication should be included for all PRN prescriptions. Altering and discontinuing prescriptions If any changes need to be made to an existing prescription e.g. a dose increase or change of route, that prescription should be re-written with a new start date in the second column or in its entirety if the second column is full; do not just overwrite the new dose on the existing prescription. For any item that needs to be discontinued, the stop date should be completed and the remainder of the administration section should be crossed through and signed to indicate who cancelled the prescription. If the prescription itself is crossed through to cancel it, care should be taken not to obscure any of the original information. When a drug chart is re-written, each page of the old chart should be struckthrough to cancel it. The front of both the old and new chart should be endorsed to indicate who re-wrote the drug chart and when. The original commencement date of each prescription should be documented, not the date the chart was re-written. Care must be taken when re-writing drug charts, as errors are easily made. Controlled Drugs on Discharge Prescriptions Must include: Patient s name and address (or unit number). The name, form (e.g. tablet, patch) and strength of the preparation. The dosage The total quantity to be supplied in words and figures either as the number of dose units (in which case make sure you know what strengths the item is available as) or the total number of milligrams to be supplied. Examples: Zomorph capsules, 20mg BD, supply 280mg (two hundred and eighty). Edition No: 2.1 Page 5
Zomorph 20mg BD, supply 28 (twenty-eight) x 10mg capsules Zomorph 20mg BD, supply 14 (fourteen) x 20mg capsules incorrect as Zomorph does not come in a 20mg capsule. Must be signed and dated by the prescriber. See Appendix 6 for full controlled drug procedures. Intravenous Drugs/ Rate-controlled infusion devices. Any medications to be administered via an intravenous or subcutaneous syringe driver should be prescribed in the appropriate section of the drug chart. Ensure that you prescribe an appropriate diluent and syringe volume. Where more than one drug is being used in the same syringe, you must ensure that these drugs are compatible. Contact the pharmacy for advice. Any drugs for addition to infusion fluids must be prescribed on the infusion therapy section of the chart. You must ensure that the drug is compatible with the fluid prescribed. Antimicrobial Prescribing (excluding paediatric antimicrobial prescribing) All antimicrobials must be prescribed on the antimicrobial therapy section of the drug chart. All prescriptions for antimicrobials must be reviewed 48 hours after antimicrobial initiation. This date must be clearly documented on the prescription chart. An antimicrobial action plan must also be made and documented in the clinical notes on this review date. If antimicrobials are to continue further review dates must be documented. Completion dates should be clearly documented on the chart to validate the antimicrobial course. As specific as possible an indication for use must be documented on the drug chart when the prescription is written (Chest infection or Respiratory Tract Infection are not appropriate indications). This should be updated as further details about the diagnosis are known e.g. culture and sensitivity results. Gentamicin and IV Vancomycin maintenance doses must be prescribed on the separate subsection of the antimicrobial pages (Page 5). When initiating Vancomycin a loading dose must be given. Probiotics (Biokult) must be prescribed when antimicrobials are initiated, unless contraindicated (see probiotic Guidelines). Dose and administration must be documented on the probiotic section of the prescription chart (Page 5) Once-weekly drugs/ unusual frequencies A small number of drugs are administered once a week only. This includes oral methotrexate and some bisphosphonate preparations. These items should be prescribed on page 16 of the drug chart. An entry should also be made in the main section of the drug chart highlighting that there is a once weekly item to be given. Any regular drugs which are not to be given daily (e.g. metolazone 2.5mg on alternate days; epoetin sc injection 3 times per week) must have the relevant daily administration boxes crossed out. Reducing doses must also have any doses not to be given crossed through/ cancelled (e.g. amiodarone loading dose, diazepam reducing regime for alcohol withdrawal)with a new start date in the second column or in its entirety if the second column is full; do not just overwrite the new dose on the existing prescription. Insulin Prescribing The proprietary name of the insulin should be used e.g. Lantus rather than Insulin glargine. The dosage must always be expressed in units (not u or iu ) The type of insulin device used should be recorded. Edition No: 2.1 Page 6
The administration times should be appropriate to the action profile of the type of insulin. Intravenous insulin infusions are prescribed on the separate section on page 17 of the drug chart. Additional specialist drug charts The intensive care unit uses a specialist drug chart for its patients and is moving to an electronic E Prescribing system. When a patient leaves the unit, medication must be transcribed to a standard Trust drug chart for use on the ward. Intravenous chemotherapy must be prescribed on a separate green prescription sheet/ pro-forma. Only suitably trained registrars and above may prescribe this therapy. Prescriptions for intravenous monoclonal antibodies must also be written on this prescription chart. An electronic prescribing system for oncology is In progress of being implemented. Intrathecal chemotherapy may only be prescribed by Consultant Haematologists whose name is on the Intrathecal Register, using the Kent Oncology Network Intrathecal Prescription Sheet. Patient controlled analgesia and epidural analgesia are prescribed on a separate prescription sheet for this purpose. Medication given in the Emergency Department (ED) may be prescribed on the front of the ED short stay drug chart, but can also be prescribed in the ED triage notes. Anaesthesia and other peri-operative medication are prescribed in the operative notes. Separate drug charts are used for paediatric patients and on neonatal intensive care and adult intensive care. Anticoagulation prescribing Oral anticoagulants (Vitamin K antagonists must be prescribed in the anticoagulation section of the drug chart. All details of the upper section of the chart must be completed: Name of the anticoagulant (not always warfarin) Details of anticoagulation i.e. indication, duration of treatment, INR range For new patients indicate if the risks and benefits have been considered and if a hematology follow up appointment is required. For existing patients the pre-admission dose and regular anticoagulation clinic should be documented. Relevant clinical details; interacting drugs and medical conditions that affect anticoagulation (these details may be documented in the additional information box on page 21 of the drug chart. An entry needs to be made on the regular side of the drug chart to indicate that anticoagulant therapy has been prescribed on the anticoagulation section of the drug chart. Critical Care Prescribing Prescriptions used in a critical care setting but not appropriate on a general ward must be cancelled before a patient is transferred to a general ward e.g. PRN electrolyte supplements, inotropes. Prescribing opioids Review any previous use of opioids, particularly recent administration, prior to prescribing Ensure that where a dose increase is intended that it is safe for the patient, usually no more than a 30-50% increase on the current dosage. Edition No: 2.1 Page 7
Ensure you understand dose conversions/ equivalency e.g. switching from immediate-release oral morphine to modified-release, switching from modified release oxycodone to fentanyl patches, Ensure you are familiar with the drug characteristics e.g. Fentanyl patches take approx 18 hours to reach maximum effect, Oxycodone Modified Release tablets provide a proportion of their dose as immediate-release and a proportion as slowrelease. PRN naloxone must be prescribed for all patients prescribed an opioid. Medication to be administered via enteral feeding tubes Where medication is to be administered via an enteral feeding tube, the route must be written as NG/ PEG/ PEJ. Where a medication is not available as a liquid preparation suitable for administration via an enteral tube, contact pharmacy for advice regarding alternatives. Administration of many drugs via an enteral tube is unlicensed (e.g. crushing tablets, IV preparations given enterally) and the prescriber takes responsibility for this. Informed consent should be obtained. Not all oral liquids are suitable for administration via feeding tubes; contact pharmacy for advice. Prescribing flushes for intravenous lines and indwelling catheters Heparin should not normally be used for flushing peripheral intravenous catheters. Heparin should only be prescribed for flushing arterial or central intravenous catheters if guidelines specifically state it must be used. All other preparations for flushing intravenous lines must be prescribed. Nursing staff may only administer a flush against a valid prescription or using a Patient Group Direction. Prescribing cytotoxic drugs. F1 and F2 doctors may not prescribe any cytotoxic drug, including for non-cancer conditions (for example, methotrexate for rheumatoid arthritis). Prescribers should refer to BNF Chapter 8: Malignant Disease and Immunosupression if they are unsure whether a particular agent is cytotoxic. When prescribing oral cancer chemotherapy outside of a specialist area, you must ensure you are familiar with the relevant treatment protocol, treatment plans and how to monitor the treatment, including monitoring for toxicity. Please refer to Appendix 2 for full details of prescribing cytotoxic and immunosuppressive therapy for inpatient admissions. Prescribing Oxygen Oxygen should be prescribed in accordance with BTS guidelines (do not cover critical care or paediatrics), using the oxygen therapy section of the drug chart. In an emergency oxygen should be given first and retrospectively prescribed on the drug chart. Loading Doses Prescribing a loading dose can involve complicated calculations and/ or regimes. Incorrect prescription of a loading dose carries the risk of under- or overdosing a patient, so care should be taken to ensure loading dose prescriptions are clear and unambiguous, and that a complete loading dose regime is prescribed. Guidance has been produced by the Pharmacy department to aid prescribers in writing prescriptions for some of the more commonly used/ high risk medications that require a loading dose. Guidance on warfarin can be found on page 20 of the drug chart or pharmacy can be contacted for advice. Edition No: 2.1 Page 8
It is a prescriber s responsibility to ensure that information about any newlyprescribed loading dose is communicated directly, and in a timely manner, to the nurse responsible for the patient s care. 3 Other notes on using Prescription Charts 3.1 The allergy status must be completed either by the prescribing doctor or admitting nurse. Nurses must not administer medicine if this box is not completed. Pharmacy must not dispense items if the allergy box is not completed. 3.2 When writing discharge prescriptions ( TTOs ) the prescriber should carefully check on completion that it has been written correctly and that there are stop dates on all appropriate medications, especially antibiotics. 3.3 The primary responsibility to prescribe clearly and accurately lies with the prescriber. Pharmacists are authorised to rewrite prescriptions that they think are illegible or unsafe if the prescriber is not available to do this. Feedback should be given to the prescriber to encourage future good practice. 4 Monitoring and Review What will be monitored How/Method/ Frequency Lead Reporting to Deficiencies/ gaps Recommendation s and actions Policy review First review in one year and then every three years Chief Pharmaci st Director of Operations Clinical Support Services Where gaps are recognised action plans will be put into place Edition No: 2.1 Page 9
5 Equality Impact Assessment Statement & Tool Appendix 1 1 Does the policy/guidance affect one group less or more favourably than another on the basis of: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation 2 Is there any evidence that some groups are affected differently? 3 If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4 Is the impact of the policy/guidance likely to be negative? 5 If so can the impact be avoided? 6 What alternatives are there to achieving the policy/guidance without the impact? 7 Can we reduce the impact by taking different action? Yes/No No Comments All public bodies have a statutory duty under the Equality Act 2010. To have due regard to the elimination of discrimination, harassment, victimisation and any other conduct prohibited by the Act The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none is placed at a disadvantage over others. This document was found to be compliant with this philosophy. Equality Impact Assessments will ensure discrimination does not occur also on the grounds of any of the protected characteristics covered by the Equality Act 2010. END OF DOCUMENT Edition No: 2.1 Page 10
6 GUIDANCE FOR PATIENTS ADMITTED ON CHEMOTHERAPY / CYTOTOXIC / IMMUNOSUPPRESSANT TREATMENT TO MEDWAY HOSPITAL Appendix 2 How do I know if a drug is immunosuppressant / cytotoxic? There is a long and growing list of these drugs. Most are in sections 8.1 and 8.2 of the BNF - if in doubt ask! 1. Patients taking oral anticancer chemotherapy for HAEMATOLOGY / ONCOLOGY INDICATIONS: DO NOT PRESCRIBE : They should NOT have any further doses of their anti-cancer treatment prescribed by the admitting medical or surgical team, dispensed by pharmacy or administered by the nursing staff. This includes all drugs listed in BNF section 8.1 as well as thalidomide and lenalidomide. Hormonal therapies can be continued unless clinically no longer required or currently contra-indicated. The patient s haematologist or the Acute Oncology Service (AOS bleep 826/812 or Ext 6057) should be contacted urgently (within 24 hours of admission) to decide whether treatment should continue during the admission. Out of hours: Oncology consultant on call via MTW switchboard. Haematology call on call consultant If the decision is made to continue treatment, the AOS consultant / haematologist is then responsible for ensuring that the necessary inpatient chemotherapy prescription is written and this is by a prescriber locally registered as holding the relevant competency. The prescription must include the duration of treatment. Trust pharmacy and nursing staff should not dispense or administer oral chemotherapy unless it has been prescribed in this way. The use of GCSF is permitted under this guidance if indicated but should be on the advice of the patient s haematologist or the Acute Oncology Service whose details and advice should be documented in the medical notes or on the drug chart. 2. Patients taking CYTOTOXICS / IMMUNOSUPRESSANTS or ANTI-TNF drugs (e.g. methotrexate, azathioprine, mycophenolate, adalimumab, etanercept this list is not exclusive) for AUTO-IMMUNE CONDITIONS (e.g. Rheumatoid, Crohn s, colitis, myasthenia, dermatology indications): DO NOT PRESCRIBE. Discuss with admitting consultant to assess whether benefits outweigh risks and record the decision in the case notes. In general, avoid prescribing if patient septic or has impaired renal or hepatic function. If decision to continue is made the prescription (excluding methotrexate see further information below) must be written by consultant / registrar. Inform the initial prescribing consultant (e.g. rheumatology, gastroenterology, dermatology, neurology) of the admission urgently (next working day) and the decision to continue or withhold documented in the notes. Methotrexate Due to the risks of drug interactions and incorrect prescribing methotrexate will generally not be restarted during inpatient stay and the decision to continue must be made by the initiating specialist consultant e.g rheumatologist, gastroenterologist or dermatologist and recorded in the medical notes. If methotrexate is deemed appropriate to restart then it must be written by the admitting team s consultant/registrar as a weekly dose. Edition No: 2.1 Page 11
Methotrexate - patients pre- and peri-operative Stop at the point of admission for surgery. For all patients on methotrexate (both medical and surgical) ensure any infection has cleared, they have finished antibiotics and have normal renal function, FBC and LFTs before considering prescribing as an inpatient and only if there is a clinical need. If in any doubt on whether methotrexate should be restarted as an inpatient then contact the initiating specialist consultant e.g. rheumatologist, dermatologist, gastroenterologist and not the consultant for that episode. In the rare circumstance that you are unable to obtain advice form the initial prescribing consultant then do not prescribe methotrexate. If methotrexate is deemed appropriate to restart then it must be written by the admitting team s consultant/registrar as a weekly dose. Information should be included on the TTA concerning the decision made by the initiating specialist so the GP and patient is clear when the methotrexate can be restarted. Methotrexate on discharge Ensure that methotrexate is included in the discharge summary and inform the patient that they may restart methotrexate after discharge. Methotrexate may be restarted immediately after discharge if any wound is healing well and the patient is infection-free. If any concerns about restarting methotrexate after discharge then discuss with the initial prescribing consultant or their consultant colleague. 3. Immunosuppressant therapy for TRANSPLANT PATIENTS (e.g. mycophenolate, tacrolimus): DO NOT STOP unless clinically indicated. CONTACT THE PRESCRIBING TEAM (eg Kings) URGENTLY (same day) Edition No: 2.1 Page 12