Prescribing

Prescribing can be a risky business, especially when prescribing for older people or children. Charlotte Hudson talks about the risks and what you can do to make sure you avoid them

At a glance

Prescribing can be fraught with complications: overprescribing, transferring incorrectly to new charts, prescribing for the wrong patient, incorrect dosages, interactions, and allergies. You should have a good knowledge of pharmacology and the legislation surrounding drugs, as well as your practice’s protocols and controlled drug routines. If you are unsure, ask.

The Medical Council, in its Guide to Professional Conduct and Ethics (2009), states that when prescribing medicines: “You must ensure as far as possible that any treatment, medication or therapy prescribed for a patient is safe, evidence-based andin the patient’s best interests.”¹

The guidance also states: “You should be particularly careful when prescribing multiple medications in case the combination might cause side-effects. You should also take particular care when prescribing for patients who may have an impaired ability to metabolise the medication prescribed. You should weigh up the potential benefits with the risks of drug adverse effects and interactions when deciding what to prescribe. This also applies to the exercise of the prescribing of generic drugs. A patient’s treatment regime should be reviewed periodically.”

Whether prescribing errors result in harm to patients depends on a number of factors, but certain patients are at particularly high risk and it is important to be aware of the drugs that are commonly associated with morbidity in general practice.

Risks associated with medication errors are particularly high in the following groups of patients:

The elderly, particularly when frail
Those with multiple serious morbidities
Those taking several potentially hazardous medications
Those with acute medical problems
Those who are ambivalent about medication taking or have difficulty understanding or remembering to take medication.

With these patients, it is important to take particular care when first prescribing, to prioritise medication review, and to check for any communication issues.

Older patients

In the Irish population, 90% of those aged over 75 years take medications regularly, and one in five of those over 50 years regularly take five or more medications (ie, polypharmacy).

Polypharmacy potentially puts the ageing population at greater risk of inappropriate prescribing, non-adherence and adverse drug reactions.³

What can you do to help?

Help older patients with the practical aspects of drug taking – reminder charts, compliance aids (eg, a medication organiser) and specially written instructions. The physical effects of ageing, such as arthritis and failing eyesight and memory, can cause issues for older people in taking medicines the way you intended.
Try to keep their drug schedule as simple as possible. When starting a new drug, keep the dosage low at first. The ageing body can be more susceptible to the side effects of medicines – be careful not to write off side effects of medication as the effects of ageing.
As most prescriptions for older people are repeat prescriptions, regular review is essential.
Monitor patients for side-effects of medications – this can help to identify problems before they result in serious patient harm.

Children

Children have a very different response to drugs. Special care is needed in ensuring the drug prescribed is appropriate and that the correct dosage is given, especially in the neonatal period.

This is particularly true for drugs that are started in secondary care. The Irish Medicines Formulary (IMF)⁴ contains information on dosing in specific populations, including adults, children, the elderly and those with impaired renal or hepatic function.

When writing a prescription for patients under 12 years old, you are required to include the patient’s age or date of birth.

Adverse drug reactions

Adverse drug reaction profiles in children may differ from those seen in adults. You should report suspected drug reactions to the Health Products Regulatory Authority, even if the product is being used in an off-label manner or is an unlicensed product.

Advice for safer paediatric prescribing

Limit the drugs you use to a well-tried few and familiarise yourself with their dosages, indications, contraindications, interactions and side-effects. Refer to a paediatric formulary when appropriate.

If you are prescribing in very small amounts of less than 1 milligram, prescribe in micrograms (written out – not abbreviated) to avoid confusion over the placing of decimal points.

When prescribing for a child, it is particularly important to give the parents all relevant information such as:

Name of the drug
Reason for the prescription
How to store and administer the drug safely (if appropriate)
Common side-effects
How to recognise adverse reactions.

Parents must always be warned about side-effects, particularly those that will be distressing to the child. It is also helpful to remind them of the importance of storing drugs in their labelled containers and out of the child’s sight and reach.

Substance misusers

Some practices will register substance misusers for their primary healthcare needs, but leave treatment of their addiction to a local drug treatment centre. Others may get more involved, offering prescribing services, for example. Find out what the arrangement is in your practice.

The Medical Council, in its Guide to Professional Conduct and Ethics (2009), states:

“You should ensure you have appropriate training, facilities and support before treating patients with drug dependency or abuse problems.”

It also states: “You must be aware of the dangers of drug dependency when prescribing benzodiazepines, opiates, and other drugs with addictive potential.”

Clinical Risk Self Assessments

Clinical Risk Self Assessments (CRSAs) conducted by MPS in more than 153 general practices in the UK and Ireland in 2013 revealed that more than 95% faced risks related to prescribing.

The most common risk was uncollected scripts, with more than 52% of all the practices visited having this problem, followed by more than 49% having repeat prescribing policy issues – either they didn’t have a policy in place, the one they have has insufficient detail, or the one they have is not adequate.

Prescriptions should clearly identify the patient, the drug, the dose, frequency, route of administration and start/finish dates, be written or typed and be signed by the prescriber. Take care that the correct information is typed up/written down.

You should ensure that you know as much about the patient as you can, for example, being aware of and documenting a patient’s drug allergies.

The most common problems with communication occur between the doctor and patient, but there are also major issues at the interface between primary and secondary care – good handovers require good leadership and communication.

You should ensure you are familiar with the side-effects and contraindications of the medicines you are intending to prescribe. You should also be aware of guidance relating to the clinical and cost effectiveness of the medicines you are prescribing.

Verbal prescriptions are only acceptable in emergency situations and should be written up at the first available opportunity. Particular care should be taken that the correct drug and dose is used.

The UK's National Prescribing Centre (NPC), in 10 Top Tips for GPs - Strategies for Safer Prescribing,⁵ advises:

Keep yourself up-to-date in your knowledge of therapeutics, especially for the conditions you see commonly
Before prescribing, make sure you have all the information you need about the patient, including co-morbidities and allergies
Before prescribing, make sure you have all the information you need about the drug(s) you are considering prescribing, including side-effects and interactions
Sometimes the risks of prescribing outweigh the benefits and so before prescribing think: ‘Do I need to prescribe this drug at all?’
Check computerised alerts in case you have missed an important interaction or drug allergy
Always actively check prescriptions for errors before signing them
Involve patients in prescribing decisions and give them the information they need in order to take the medicine as prescribed, to recognise important side-effects and to know when to return for monitoring and/or review
Have systems in place for ensuring that patients receive essential laboratory test monitoring for the drugs they are taking, and that they are reviewed at appropriate intervals
Make sure that high levels of safety are built into your repeat prescribing system
Make sure you have safe and effective ways of communicating medicines information between primary and secondary care, and acting on medication changes suggested/initiated by secondary care clinicians.

References

Medical Council, Guide to Professional Conduct and Ethics for Registered Medical Practitioners (2009) www.medicalcouncil.ie
Medical Council, Talking About Good Professional Practice www.medicalcouncil.ie
TILDA, Polypharmacy in Adults Over 50 in Ireland: Opportunities for Cost Saving and Improved Healthcare (2012) http://tilda.tcd.ie
Irish Medicines Formulary www.formulary.ie
NPC, 10 top tips for GPs: Strategies for Safer Prescribing (2011) www.npc.nhs.uk

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