Good prescribing practice - General advice
This guideline provides brief guidance on good prescribing practice. See the NHSGGC Medicines Reconciliation Policy on StaffNet for more details.
On admission - as soon as possible (within 24 hours)
- Obtain complete and accurate medication history using a minimum of two information sources. The default should be the Emergency Care Summary (ECS) and the patient where possible. Other sources of information include GP Practice, nursing home records, community pharmacy, Clinical Portal.
- Resolve any discrepancies between the information sources and document clearly in the medicines reconciliation form.
- Complete medicine reconciliation (see Assessing Medicines on Admission in Acute Patients for general principles to consider for each medicine patient is taking on admission).
During admission - before prescribing:
- See Assessing Medicines on Admission in Acute Patients, for general principles.
- Ensure each medicine is appropriate and safe for the patient by checking for allergies / sensitivities, history of adverse reactions, any factors which could affect the patient's drug handling ability (e.g. renal or hepatic impairment, drug interactions, weight), formulary status of drug, ability to take oral medicines, compliance issues.
- Continually review the need for each drug e.g. if patient is on IV antibiotics then review daily and switch to oral therapy when clinically appropriate (see IV - Oral Antibiotic Switch Therapy (IVOST) policy).
- Monitor patient for potential and actual adverse reactions.
- Document any medication changes and the reason.
Medication Incident Reporting
- A medication incident is an error or adverse event involving a medicine which causes harm or potentially could cause harm to a patient. Many are preventable.
- All staff (medical, nursing, pharmacy) must ensure that medication incidents are reported, even near misses. This is an important part of our learning system to make improvements to patient care.
- Use DATIX, access via StaffNet, to report all incidents. Incidents should be managed and investigated as per NHSGGC Incident Management Policy and Management of Significant Clinical Incidents Policy on StaffNet.
Minimising medication incidents - on the Kardex ensure:
- Drugs are written legibly and in full using generic drug names wherever possible unless there is bioequivalence issues for different formulations e.g. controlled release preparations of theophylline, lithium or phenytoin, then prescribe by brand as a different brand can result in ineffective therapy or toxicity.
- Drugs prescribed on a separate prescription chart e.g. warfarin, insulin, gentamicin are also prescribed on the Kardex with reference to the separate chart.
- Drug frequency is clear e.g. if once weekly then strike out the 6 days when the drug is not to be administered. If a drug is to be taken 'when required' then specify the maximum frequency not to be exceeded.
- For courses of treatment the duration or review date for drug(s) is stated e.g. antibiotics, steroids.
- 'Micrograms', 'nanograms', 'units' are written in full e.g. 10U insulin could be read as 100 of insulin. For liquids prescribe as 'mg' not in 'ml' as different strengths of liquids may be available.
- If a decimal point is unavoidable then the dose is carefully prescribed e.g. '0.3mg' rather than '.3mg' and '2mg' rather than '2.0mg'.
- The reason for stopping a drug is stated.
- Sign and date all prescriptions - if a prescription chart is re-written then the date against each drug entry should be the date the medicine was originally prescribed, not when the prescription was re-written.
- As the discharge prescription (Immediate Discharge Letter, IDL) is often the first communication the GP will receive regarding a patient's hospital admission, review all medicines before discharge, including any withheld during admission. For more details on discharge processes see Medicines Reconciliation Policy on StaffNet. For guidance on prescribing controlled drugs on discharge, see Controlled Drug Prescribing.
- Ensure patient or their relative / carer is aware of any medication changes.
- Prepare IDLs in adequate time to allow dispensing of the medicines. Ideally 24 hours in advance of planned discharge.
- Annotate clearly on prescription if patient receives medicines in a compliance aid device and, ideally, details of the community pharmacy which provides this.
- If changes are required to medicines in the IDL after it has been sent for pharmacy review, then pharmacy must be informed immediately by phone so that changes can be made to the dispensed prescription.
These are used widely but may not always be suitable or appropriate for the patient. If a new compliance aid is being considered for a patient then contact your ward pharmacist / pharmacy dispensary in advance of writing the discharge prescription to discuss suitability and whether the community pharmacy can continue the service. Assessing a patient for a compliance aid may be better done after discharge to their home environment.