BENDIGO HEALTH PHARMACY DEPARTMENT Inpatient prescribing Patient identification

BENDIGO HEALTH PHARMACY DEPARTMENT Inpatient prescribing

Patient identification is essential for safe drug prescribing and administration Patient identification must be visible on all sections on the drug chart – FRONT & BACK Only 28% of charts had correctly completed patient ID 111111 BLOGGS, Mr. Joe 1 Cumming St 26/10/1939 Male, 69 years, 3 months Bendigo VIC, 3550 Ph: 5454 9003 Ward: MED MC: 20893525471 Public- Eligible AMU- Acute Medical unit Adm: Thursday 7 th January 2016 GP: dr SMITH John, Medcial medical Clinic Joe Bloggs 75 kg

Allergies and Adverse Drug Reaction (ADR) Alerts • Medical officers, registered nurses and pharmacists are obliged to complete If a previous ADR exists, list the following: ADR details for patients – when asking a patient use terms such as ‘allergy l Drug name or side effects’ l • Reaction details (e. g. rash, diarrhoea, anaphylaxis) Once information has been verified and documented, the person l Date of reaction (if possible) documenting the information must SIGN, DATE and PRINT THEIR NAME l • Who recorded the information When documenting any additional information – the person adding the information must initial the designated area

Allergies and Adverse Drug Reaction (ADR) Alerts Ibuprofen GI bleed (2014) T. Smith 07/01/2016 • Medical officers, registered nurses and pharmacists are obliged to complete If a previous ADR exists, list the following: ADR details for patients – when asking a patient use terms such as ‘allergy l Drug name or side effects’ l • Reaction details (e. g. rash, diarrhoea, anaphylaxis) Once information has been verified and documented, the person l Date of reaction (if possible) documenting the information must SIGN, DATE and PRINT THEIR NAME 35% OF ADRS WERE l • Who recorded the information When documenting any additional information – the person adding the information must initial the designated area NOT COMPLETED PROPERLY

Regular Medication orders A drug order is only valid if: • All patient identification is completed The prescriber enters all of the following: – Date – Generic name (active ingredient name) – Slow release box is ticked when applicable – Route – Dose calculation (paediatric charts only) – Frequency and administration times – Indication – Prescriber signature, print name and contact (pager number) FILL IN ALL THE BOXES

DANGEROUS ABBREVIATIONS DO NOT USE IN MEDICATION ORDERS ROMAN NUMERALS ARE NOT PERMITTED Large lists of abbreviations can be hard to memorise. This is a short list of the DANGEROUS abbreviations which we should NOT use Error Prone Abbreviation Intended meaning Misinterpretation Correct Abbreviation Ug, mcg or μg microgram Mistaken for milligram when handwritten microgram or microg U or u unit Mistaken as the numbers ‘ 0’ or ‘ 4’, causing a 10 -fold overdose or greater (e. g. 4 U seen as ‘ 40’ or 4 u seen as ‘ 44’). unit(s) OD, od or d Once a day Once daily Mistaken for twice a day d is easily missed daily or the specific time QD or qd Every day Mistaken as qid (four times a day) daily Q 4 h Every 4 hours Every 4 hrs, 4 hourly, 4 hrly 32% OF DRUG ORDERS HAD SOME SORT OF ERROR PRONE ABBREVIATION SC subcutaneous Mistaken for sublingual subcut or subcutaneous SL or S/L sublingual Mistaken for SC & interpreted as subcutaneous subling or sublingual No zero before decimal point (e. g. . 5 mg) 0. 5 mg Misread as 5 mg 0. 5 mg or write 500 microgram or 500 microg Trailing zero after decimal point (e. g. 5. 0 mg) 5 mg Misread as 50 mg Do not use trailing zero after decimal points or after whole numbers

VTE Prophylaxis MEDICAL ADULT VTE Risk Screening Tool (see full policy on PROMPT) LMWH = low molecular weight heparin UFH = low dose unfractionated heparin IPC = intermittent pneumatic compression GCS = graduated compression stockings FEATURES High Ischaemic stroke Acute on chronic lung dis. Acute on inflammatory dis. Cancer Decompensated heart failure Acute spinal cord injury High LMWH or UFH Moderate Consider LMWH or UFH Version 1. 7 th May 2012 Medical conditions with additional VTE risk factors: Immobility Acute inflammation Thrombophilia Pregnancy or puerperium Oestrogen therapy Acute infection Obesity Family history of VTE Withhold 1 st dose 24 hours post thrombolysis LMWH Printed History of VTE Active cancer Age > 60 years Myocardial infarct 3 Guide to accessing IDEA DURATIONS PROPHYLAXIS RISK Until resolution of acute medical illness or hospital discharge Pharmacy Department tel: 9003 Printed version 1. 01/05/2014 SURGIAL ADULT VTE Risk Screening Tool (see full policy on PROMPT) LMWH = low molecular weight heparin UFH = low dose unfractionated heparin IPC = intermittent pneumatic compression GCS = graduated compression stockings FEATURES Major trauma Major orthopaedic trauma Hip fracture surgery Hip or knee arthroplasty Major surgery and age > 40 years Major surgery definition: All intraabdominal including laparoscopic Duration >45 mins Any surgery with prior VTE &/or active cancer RISK High LMWH or UFH GCS +/- IPC High DURATION PROPHYLAXIS LMWH GCS +/- IPC 5 – 10 days or fully mobile See Orthopaedic VTE Policy LMWH or UFH GCS +/- IPC 5 – 10 days or fully mobile (cancer surgery consider 28 days) 5 – 10 days or fully mobile Other surgery with additional VTE risk factors: Immobility Thrombophilia Oestrogen therapy Obesity Pregnancy/ puerperium Acute inflammation Acute infection Family history of VTE Moderate Consider LMWH or UFH Consider GCS Until discharge

VTE Prophylaxis The VTE prophylaxis section in the medication chart is designed to improve the documentation of VTE risk assessment and increase the prescription of VTE prophylaxis (pharmacological and mechanical) in patients at risk of developing a VTE and in whom prophylaxis is indicated The VTE prophylaxis section is in the regular medications section and is highlighted in red to remind clinicians to assess VTE Risk and Prescribe VTE prophylaxis if indicated 11% OF CHARTS HAD VTE RISK ASSESSMENT COMPLETED 14/01 S/Cut Enoxaparin 40 mg 0800 Daily T. Smith 200

Joe Bloggs’ Medication orders Pre-admission meds – Seretide 250/25 ii puffs inh bd – Metformin XR 1000 mg i tab o morning Hospital initiated meds: – Benzylpenicillin 1. 2 g IV every 6 hours – Prednisolone 30 mg for 2/7, then 25 mg for 2/7 – Enoxaparin 40 mg sc daily – Paracetamol 500 mg ii tabs o every 6 hours prn

Regular Medication orders Seretide 250/25 inhale ii puffs bd If the order is recharted –the date on which the order is re-written should be entered on the new order (not the date it was originally prescribed) 7/1 inh Seretide 250/25 2 puffs 08: 00 12 hrly 20: 00 pneumonia T Smith 154 Dose: must be written using metric (e. g. grams, litres and Arabic system (e. g. 1, 2, 3). Always use a zero (0. ) before a decimal point but never after the decimal point. If possible it is preferable to state the dose in whole numbers and not decimal ( write 500 mg instead of 0. 5 g or write 125 EVERY order must have a signature & NAME PRINTED microg instead of 0. 125 mg) Don’t use U or IU for units – they can be misread as 0 or 10. always write units in full

Slow Release Drugs Metformin XR 1000 mg i tab orally morning 7/1 PO T 2 DM Metformin XR 1000 mg T. Smith 08: 00 mane 154 Good practice to also write out the SR, MR, XR, CD The red Tick if Slow Release box is a prompt to prescribers to consider whether or not the standard release form of the drug is required

Regular Medication orders Benzylpenicillin 1. 2 g IV every 6 hours 7/1 IV Benzylpenicillin 1. 2 gram 06: 00 12: 00 18: 00 24: 00 6 hrly pneumonia T Smith 154

Variable Dose For drugs that require drug concentration monitoring document the following for each day of therapy • Drug level result • Time drug level taken 7/1 15 7/01 8/1 9/1 10/1 Prednisolone O 30 mg 25 mg once daily Pneumonia 0800 T. Smith 154 For each dose the prescriber must document: • Dose • Prescriber initials • Time to be given

PRN medication order Paracetamol 500 mg ii tabs every 6 hours prn 7/1 O Paracetamol 1 g 6 hrly 4 g T. Smith 154 Pain

Changing/Ceasing orders benzylpenicillin 1. 8 grams IV 1. 2 grams every 6 hours 7/1 06: 00 pneumonia 12: 00 18: 00 24: 00 J. Hibbert 154 NOT ONE ORDER WAS CEASED/CHANGED CORRECTLY

Changing/Ceasing orders 7/1 IV benzylpenicillin 1. 2 grams pneumonia 8/1 IV 06: 00 every 6 hours 12: 00 T. Smith 18: 00 24: 00 154 benzylpenicillin 06: 00 1. 8 grams every 6 hours pneumonia J. Vu 200 12: 00 18: 00 24: 00 increased dose 8/1/16 J. Vu

Other examples Intermittent Orders 7/1 O Thyroxine 100 microg alt days Hypothyroidism T. Smith 0730 Empty stomach , ½ hr before breakfast 154 X X X

Warfarin Prescribing For each day of therapy document: • INR result (if ordered) • Warfarin dose • Prescriber’s initials 2. 3 14/01 7 2– 3 O Atrial fibrilation T. Smith 154

Once only and Nurse initiated medicine orders The Once Only, Pre-medication, Telephone Orders and Nurse initiated Medicine sections are found on the front page of the drug chart. These orders are separate from regular medications so as to reduce the risk of continued administration.