Prescribing - core skills series

Prescribing can be a risky business, especially when prescribing for different kinds of patients such as older people or children who can be particularly vulnerable. Charlotte Hudson talks about the risks and what you can do to make sure you avoid them.

From over-prescribing, transcribing incorrectly to new charts and prescribing for the wrong patient, to incorrect dosages, interactions and allergies, prescribing is fraught with complications. It is imperative that you have a good knowledge of the pharmacology and the legislation surrounding drugs, and the trust protocols and controlled drug routines – if unsure, ask.

The GMC’s Good practice in prescribing and monitoring medicines and devices (2013)1 says: “You must prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health, and are satisfied that the drugs or treatment serve the patient’s needs.”

The guidance also states that you are responsible for the prescriptions you sign and your decisions and actions when you supply and administer medicines and devices or authorise or instruct others to do so. You must be prepared to explain and justify your decisions and actions when prescribing, administering and managing medicines.

A systematic review in 2009, which focused on UK studies, found a prescribing error rate of around 7.5% and showed that around one in 15 hospital admissions are medication related, with two thirds of these being preventable.2

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.

The ageing body can be more susceptible to the side effects of medicines

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

• the old, 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.

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

Older patients

Four out of five people aged over 75 years take at least one medicine, and 36% of this age group take four medicines or more.3 This increases the number of potential drug interactions, and increases the chance of side effects and problems taking them correctly. The ageing body can be more susceptible to the side effects of medicines.

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, ensure that the dose is in keeping with the recommended starting dose for older patients.
• 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.

The most important effect of age on medication is a reduction in renal clearance. Many older patients therefore excrete drugs slowly and are highly susceptible to nephrotoxic drugs. This effect may be exacerbated by an acute illness, particularly one that causes dehydration.

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 BNF for Children4 provides practical information on the use of medicines in children of all ages from birth to adolescence and, in 0–18 Years: Guidance for all Doctors,5 the GMC states you should be familiar with this.

Special care is needed in ensuring the drug prescribed is appropriate and that the correct dosage is given, especially in the neonatal period

Adverse drug reactions

Adverse drug reaction profiles in children may differ from those seen in adults. You should report suspected drug reactions to the Medicines and Healthcare products Regulatory Agency (MHRA), even if the product is being used in an off-label manner or is an unlicensed product. The identification and reporting of adverse reactions to drugs in children is particularly important because:

• The action of the drug and its pharmacokinetics in children (especially in the very young) may be different from that in adults.
• Drugs are not extensively tested in children.
• Many drugs are not specifically licensed for use in children and are used ‘off-label’.
• Suitable formulations may not be available to allow precise dosing in children.
• The nature and course of illnesses and adverse drug reactions may differ between adults and children.6

Substance misusers

There are 197,110 adults in contact with NHS treatment services, according to the National Treatment Agency for Substance Misuse.7Many practices will register substance misusers for their primary healthcare needs, but leave treatment of their addiction to the local drug dependency unit. Others may get more involved, offering prescribing services, for example. Find out what the arrangement is in your practice.

If a substance misuser attends in relation to another matter, you should have a clear strategy if they request a prescription. They will be familiar with the system, can have a highly plausible reason why a prescription is needed, and be very persistent. There should be firm boundaries for these patients – they will probably be under an agreed contract for their treatment – so understanding the procedure in the practice will help you to deal with them.

If a substance misuser attends in relation to another matter, you should have a clear strategy if they request a prescription

Prescribing diamorphine, dipipanone and cocaine for addicts can only be done with a special licence. These and other Schedule 2 drugs must be prescribed on a particular form (which one depends on which country you are in – check the BNF for details).

Further information

• Case study: An unfortunate prescription
• MPS factsheet, Safe prescribing.

References

1. GMC, Good Practice in prescribing and monitoring medicines and devices (2013)
2. NPC, 10 top tips for GPs: Strategies for safer prescribing (2011)
3. Department of Health, Medicines and Older People (2001)
4. British National Formulary for Children
5. GMC, Good Medical Practice (2013), 0-18 years: guidance for all doctors
6. Prescribing for Children
7. Public Health England, National Treatment Agency for Substance Misuse, Drugs and alcohol.

Clinical Risk Self Assessments

Clinical Risk Self Assessments (CRSAs) conducted by MPS in more than 100 general practices in the UK in 2013 revealed that over 95% faced risks related to prescribing.

The most common risk was uncollected scripts, with over 52% of all the practices visited having this problem, followed by over 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 current guidance from the British National Formulary (BNF). It is accessible online if your hard copy goes walkabout.

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.