PrescribingOur Roles

&Our Responsibilities

14th November 2012

Dr Julian Tomkinson

Aims• To discuss prescribing – our roles, our

problems, our responsibilities• Discuss any cases• What is good prescribing• Practical solutions• Practice

Curriculum1.THE CORE CURRICULUM STATEMENT -Being a General Practitioner

‘What limits are there to your prescribing?’2.02 THE CONTEXTUAL STATEMENT ON - Patient Safety and Quality of Care which discusses• Example of failure to arrange INR monitoring• Need to understand prescribing and monitoring of medication• Awareness of systems for prescribing• Variance in management• Polypharmacy2.04 THE CONTEXTUAL STATEMENT ON - Enhancing Professional Knowledge• Provide effective and evidence-based prescribing• Using pharmacy to help with prescribing• Adhering to the GMC’s principles of good medical prescribing• Incentive schemes• When working in secondary care see prescribing from GP eyes

Significant Event• 77 year old man prescribed amantadine for

Parkinson’s Disease• Pharmacy assistant picked up sinthrome (similar

to warfarin) and labelled as amantadine (symmetrel)

• Box identical• Patient admitted with severe haematuria• INR 7.8• Legal case on-going

Boxes look identical!

Discuss Cases

Reverse Brainstorm

You are the world’s worst prescriber

Tell me:•Your habits and techniques•Your attitudes•Your behaviours

‘A Single Competency Framework for all Prescribers’

Scenario 132 year old lady with 1 week history of cough with green sputum. Systemically well. Few crackles audible at right base.Past hx: Pneumonia requiring admission 4 years ago

• You decide antibiotics are indicated

• What do you need to know?

Scenario 1

• Past hx: Had pneumonia requiring admission 4 years ago

• Allergies: Ampicillin (extensive rash)• Medications: Cilest

Patient tells you she got nasty thrush after last course of antibiotics from dentist

Scenario 244 year old lady attends for repeat prescription

of microgynonLast entry:11/11/11:

‘pill check – happy on microgynon. Does not want implant or coil’Rx microgynon use as directed (336)

THOUGHTS?

Scenario 2 continued

BP 130/80

BMI 24.5

Smoking 20 cigarettes per day

What issues now?

UK Medical Eligibility Criteria (UKMEC)

Scenario 3

You are on a home visit:Write a prescription for30 morphine sulphate continus tablets one

twice a day for 1 month

Morphine sulphate continus tablets 30mg

Take one tablet twice daily for pain

Supply 30 (thirty) tablets

Scenario 4Max O’Dima age 44 attends for blood results

02/11/12: ‘TATT last 18 months. No stress of note. Felt colder and not as strong in the last few months. Mum and sister have hypothyroidism check bloods and review’

09/11/12: Free thyroxine 8.2TSH 37thyroid peroxidase antibody positive

Issues?

Scenario 5Carol Corpor presents to you with her son

Timmy age 3 He has a patch of inflamed skin on his right

deltoid.

Scenario 5Mum feared it was ringworm and is really scared it will spread to her 3 month old daughter who has just got home from SCBU after being born

premature at 32 weeks.

What would you advise?

Scenario 5Mum took the prescription for clotrimazole that you

prescribed last week.You receive a fax from a dermatologist she has seen

privately this morning:Dear Dr Obliging,

I saw Timmy and Carol, who are close family friends, this morning in my rooms. He has a patch of tinea corporis on his right arm. Carol is very worried about Timmy’s sister also becoming infected. I would be grateful if you could prescribe him griseofulvin. Sorry I didn’t get chance to weigh Timmy today as the scales were missing. I will send a typed report ASAP

RegardsDermotDr D E R Matthews (dermatologist)

GMC Guidance• keeping up to date and prescribing safely• need and objectivity - prescribing for yourself and those close to you• consent to prescribe - explaining benefits, risks and side effects of

medicines; improving adherence• sharing information with and prescribing at the recommendation of

colleagues• repeat prescribing, prescribing with repeats and reviewing medicines• prescribing online, by telephone and video-link• prescribing off-label and unlicensed medicines, including for reasons

of cost-effectiveness• conflicts of interest - prescribing incentives and financial interests in

pharmacies, pharmaceutical companies and dispensing practices• sports medicine - prescribing performance enhancing drugs

Is the prescription……

• Ethical ?• Evidence Based ?• Safe?• In line with practice, local and national guidance ?• Cost effective ?• Given with Informed consent ?• Practical ?• Do I understand the implications?

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

Drugs commonly associated with preventable harm in general practice

Drugs with narrow therapeutic index eg,• digoxin• methotrexate• warfarin

Drugs commonly associated with preventable harm in general practice

Other commonly used drugs• anti-thrombotics such as aspirin• cardiovascular drugs including diuretics, beta-

blockers and ACE inhibitors• CNS drugs including anti-epileptics, opioid analgesics, and psychotropics• drugs used for the treatment of diabetes• NSAIDs• systemic corticosteroids

Top 10 tips for safe prescribing1. Keep yourself up-to-date in your knowledge of therapeutics, especially for the

conditions you see commonly

2. Before prescribing, make sure you have all the information you need about the patient, including co-morbidities and allergies

3. Before prescribing, make sure you have all the information you need about the drug(s) you are considering prescribing, including side effects and interactions

4. Sometimes the risks of prescribing outweigh the benefits and so before prescribing think: ‘Do I need to prescribe this drug at all?’

5. Check computerised alerts in case you have missed an important interaction or drug allergy

Top 10 tips for safe prescribing6. Always actively check prescriptions for errors before signing them

7. 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

8. 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

9. Make sure that high levels of safety are built into your repeat prescribing system

10. 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

Some Useful Resources / References

• www.gmc-uk.org/guidance/ethical_guidance/prescriptions_faqs.asp• bnf.org BNF• www.mims.co.uk/ Mims• http://www.medicines.org.uk/emc/ Electronic Medical Compendium• www.npc.co.uk/ National prescribing centre• http://

www.npc.co.uk/improving_safety/improving_quality/resources/single_comp_framework.pdf

• http://www.npc.nhs.uk/evidence/resources/10_top_tips_for_gps.pdf• http://www.nhsbsa.nhs.uk/1127.aspx Pre-payment prescriptions• http://www.nyrdtc.nhs.uk/GMMMG/Publications/publications.html

medicines management manchester• http://

www.nyrdtc.nhs.uk/GMMMG/Groups/ipnts/ipnts_rag/ipnts_rag.php red amber green therapies

Feedback

• Divide into pairs and discuss what you have learnt today

• Tell me 2 things you will do differently in the future