Presenters: Chris Chircop, Claude El-Hayek

Vincent Viengkhou, Geoff Wills Western Sydney Local Health District

January 2019

Case Study Feedback

Content of this session

• Case 1

• Case 2

• Other prescribing tips

• Q & A

Case Study 1 • Mr Jack Citizen - MRN 000-0000; DOB: 05/01/1956;

Address: 12 Mount Street, Regal Hills, NSW 2345.

• 63 year old man presenting to ED with malaise, severe sore throat, fever and severe pain.

• Past Medical Hx: • Non-small cell lung cancer diagnosed 3 months ago

(completed chemotherapy 9 days ago). • Hypertension • Ischaemic heart disease • Peptic ulcer disease • History of MRSA

• Allergies: Penicillin (rash), elastoplast, Bactrim- sulfamethoxazole/trimethoprim (rash)

Case Study 1 • His regular medications are:

– Ramipril 5mg – Cartia 100mg daily – Somac daily – Oxycontin 30mg bd – Transiderm 50mg patch – Panadol qid PRN

• The consultant is contacted and recommends the commencement of antibiotic cover for febrile neutropenia (Tazocin, gentamicin and vancomycin). FBC pending.

• The patient weighs 70kg and is 165cm tall.

• His BP is 80/59 mmHg, HR 110 bpm and creatinine is 88 micromol/L. Suspected of septic shock.

• He is requesting additional analgesia.

Case Study 1 - Task

On the prescription forms provided: 1. Prescribe the medications for this patient. You may

choose other antibiotic regimen(s) if you have justifiable reasons for doing so

2. The registrar has also asked you to prescribe salbutamol nebulised every 2 hours for his shortness of breath.

3. Nursing staff has informed you the patient is requesting for prn analgesia. Add this to his chart.

4. It is now 5 days later. The patient is well and no longer requires antibiotics. Prescribe discharge medication(s) for this patient using the discharge scripts supplied.

Case 1 – Main Issues Tazocin

• Jack is allergic to PENCILLIN • Tazocin contains PIPERACILLIN & tazobactam, so

would not be suitable for him.

• An alternative regimen should be considered: • Cefepime IV 2g every eight hours OR • Ceftazidime IV 2g every eight hours OR • Meropenem 2g every eight hours (recommended by

local guideline)

WSLHD febrile neutropenia guideline is based on the Therapeutic Guidelines & Westmead

Hospital Antibiogram

Febrile Neutropenia Treatment

Tips - Allergy and ADR documentation • Ensure that it is completed for every patient.

• Check BEFORE each prescribing event

• If patient has a known ADR, document generic name and nature of reaction • Transcribe the ADR to the prn chart on the back

• If no ADRs tick ‘Nil known’ box

• Print name, sign and date when complete

• If reaction is unknown, write “Unknown” rather than leaving blank

• Always document the nature and severity of the reaction • Rash - Minor itch vs Steven Johnson’s

Syndrome? • ACE inhibitors - Dry cough vs angioedema? • Amoxicillin - Nausea vs anaphylaxis?

Tips - Allergy and ADR documentation

CASE 1 - Allergy documentation

Back of chart

Bactrim® is a brand; use generic name

Can you spot the problem?

Case 1 – Main Issues Vancomycin & Gentamicin

• Refer to local guidelines for dosing advice.

• VANCOMYCIN: • Use ACTUAL BODY WEIGHT for dose calculation • Use a LOADING DOSE for septic patients • Do not prescribe as variable orders (local policy)

• GENTAMICIN: • Use IDEAL BODY WEIGHT for dose calculation • Use higher dose (up to 7mg/kg) for septic patients • Prescribe in variable dose section

Case 1 – Main Issues Beware of Google!

In Australia: Cartia® = aspirin Cartia ®≠ diltiazem Use appropriate references when looking up generics

Tips - Generic Prescribing • Prevents mistakes and confusion especially during verbal

communication

• Generic names help facilitate the detection of: • Appropriateness of therapy • Duplication • Appropriateness of dose • Interactions • Allergies • Contraindications

Tips - Generic Prescribing • Brand names often look and sound similar to other drugs

e.g. Losec ®, Lasix ®, Lipex ®, Luvox®

• Generic names help convey the drug class • Coversyl ® = Perindopril, Tritace ® = Ramipril • Timentin ®, Curam®, Augmentin®, Tazocin ® = Penicillins

• This group of medications accounts for a large percentage of prescribing errors in the hospital.

• Brands names may prevent the duplication of medication orders from being recognised • e.g. orders for both generic and brand name on the

same chart

Case 1 – Main Issues Analgesia

• Prescribe S8s as both generic AND brand name for all opioids to avoid confusion.

• Writing generic alone can result in immediate release Endone being given instead of slow release Oxycontin.

Modified Release Medication

• If a patient cannot swallow, alternative options should be considered

• If help is required, ask check with pharmacist before prescribing

Tick if Slow

Release

• This box must be ticked if a sustained or modified release form of an oral drug is required (eg. XR, SR, CD, MR, EC, CR, ER, XL)

• Crushing SR dosage forms results in a drug dump

Case 1 – Main Issues Analgesia

• PRN analgesia should take into consideration the patient’s usual dose of opioids.

• Oxycontin 30mg PO bd = 60mg/day

• Options include: • Endone (oxycodone) 5mg PO every 2 hours PRN • Endone (oxycodone) 10mg PO every 4 hours PRN

• Consider laxatives for patients on opioids.

Case 1 – Main Issues Discharge Prescription

• S8 items, such as opioids, should be written on a separate prescription (one for each formulation)

• The quantity of tablets requested should be written in words and figures

Tips - Discharge Prescriptions • Include your contact number

• Only one doctor may prescribe per prescription

• Write all prescriptions with a ball-point pen to ensure it is clear, legible and will not smudge!

• Medication Reconciliation! Check discharge prescriptions after you have finished to ensure you have transcribed correctly

• Don’t write your name and DOB (common mistake)

• If requesting more than 7 day’s supply, check with pharmacy first.

Case Study 2 Mrs Betty Citizen (MRN 000-0001), DOB: 11/1/1936 is an 83 year old

woman who has developed an above knee DVT 6 days after hip replacement surgery.

Past medical history: hypertension, depression, gastro-oesophageal reflux disease, hysterectomy, osteoporosis and rheumatoid arthritis.

Nil Known Allergies

Her regular medications include: Ostelin 1 tds, Sertraline 50mg mane, Acimax 20mg bd, methotrexate 5mg on Mondays, folic acid 5mg Tuesday-Sunday and Coversyl 5mg in the morning.

Weight: 48.7kg

The consultant was contacted and recommended therapeutic enoxaparin and overlapping warfarin.

Case Study 2

Blood results are as follows:

Urea 7.8 mmol/L

Creatinine 120 micromol/L

eGFR 45mL/min/1.73m2

Case Study 2 Task

On the prescription forms provided:

1) Prescribe the appropriate medications for this patient

2) The patient is requesting analgesia for joint pain. Add this to her chart.

3) Her blood pressure has been consistently low and in view of other concurrent issues, the advanced trainee has decided to cease perindopril. Cease the order on the chart.

Case 2 – Main Issues Enoxaparin Dosing

• CAUTION: eGFR that is reported in Powerchart is based on population data that is independent of weight

• Estimate creatinine clearance (CrCl) using the Cockcroft Gault formula – most drug dosing guidelines use this for dose adjustments

• In Betty’s case: • eGFR is reported as 45mL/min/1.73m2

• Creatinine Clearance is calculated to be 24mL/min • Enoxaparin dose should be reduced to 1mg/kg once a day • Round dose to 50mg • Treatment dose of enoxaparin should be charted in regular

section of NIMC, not in VTE prophylaxis section

WSLHD Anticoagulation Guideline

Round up or down to nearest 10 mg. Comes in pre-filled graduated syringes 60mg, 80mg,

100mg.

Refer to the WSLHD Anticoagulation Guideline for all

matters related to all anticoagulants.

Case 2 – Main Issues Warfarin

• Always fill in target INR and indication

• Each dose must be signed

• 4pm timing ensures home team reviews INR result, then orders dose – record INR on chart

• Must specify the brand of warfarin used (Coumadin® if initiated at Westmead)

• Marevan® and Coumadin® not bioequivalent

WSLHD Anticoagulation Guideline

Therapeutic Guidelines- Starting dose 7.5mg daily

Betty should start on a 5mg dose due to her age and body weight.

Case 2 – Main Issues Paracetamol

• For frail, elderly patients, reduced doses of paracetamol should be given due to increased risk of hepatotoxicity (Usually a maximum of 3g/day in divided doses or 60mg/kg/day)

• Betty weighs 48.7 kg, therefore up to 3g per day is suitable for her.

• Refer to the WSLHD Clinical Guide to Paracetamol Use in Hospital Inpatients > 16 Years of Age

What’s wrong with this?

v

• Methotrexate recharted as daily. Always weekly dosing.

Case 2 - Once weekly medications • Specify the day of administration e.g. ‘on Sunday’

• Cross out the boxes on the days the medication is NOT to be administered

• Only Specialists and Registrars can prescribe Methotrexate at Westmead

What is wrong with this?

Make sure you cease the old order before writing a new one Prescribe different doses of same drug as a separate order.

Case 2 - Ceasing orders • Draw two oblique lines in the administration column

• Endorse as ceased, sign and date (cessation must be accountable)

• Draw a single oblique line through the drug name to prevent unintentional re-charting

• Do not obliterate original order

• If changing dose or frequency, cease the old order before writing the new one. DO NOT TRY TO AMEND/CHANGE THE OLD ORDER!

• It is important to draw an arrow to indicate when the new order is to commence

Other Prescribing Tips

Patient Identification • Write clearly in black ballpoint pen

• Do NOT use ‘sticky labels’ on any prescription

• Use 3 patient identifiers – full name, DOB and MRN

• Don’t forget the PRN chart: Complete front and back of chart BEFORE charting any medication

• Document weight and height (especially for the elderly, paediatrics, oncology patients andpatients on weight-based dosing medications).

Name MRN DOB

8 patients with the same name!

What’s wrong with this?

HCL (Hydrochlorothiazide intended)

What’s wrong with this?

‘od’ mistaken for bd, incorrect medication times entered, should have been once daily. Medical Officer did not enter times

Refer to this guideline for recommended prescribing

terminology and abbreviations.

Abbreviations • ONLY approved abbreviations should be used, based on

Australian Commission on Safety and Quality in Healthcare

• NEVER abbreviate medication names

• NEVER abbreviate once daily as qd or od - can be mistaken for qid or bd • daily, mane, middi, nocte are acceptable

• “q1h” may be interpreted as “q12” • use ‘every hour’, or ‘hourly’, or ‘one hourly’

• “TD” is not universally understood as transdermal – write “topical”

Dosing Times

• The medical officer writing the order MUST enter the frequency and administration times(s) when writing the medication order

• Ensure times match frequency

• What if there are more than 6 dosing times? • Cross out the lower

regular medication box to ensure that it is not utilised inadvertently for another medication

Dosing Times

Dose • Never prescribe a dose in mL alone:

• Always specify dose of medication in milligrams or include strength (mg/mL)

• Morphine available as 2mg/mL and 10mg/mL oral liquid. A 5x overdose may occur if 5mL is prescribed but 10mg intended

• Never place a decimal point and zero after a whole number e.g. 2.0mg (could be seen as 20mg) • Should be 2mg (could lead to 10x overdose)

• Never leave a decimal point ‘naked’ e.g. .5mg • Should be 0.5mg (could lead to 10x overdose)

Dose • Always prescribe dose in units (mg, microgram,

international units etc)

• Do not prescribe as ‘1 Tablet’

• Never abbreviate microgram as mcg or μg • Can be interpreted as mg • Write ‘microg’

• Never abbreviate units as U or IU • Can look like a zero = 10x overdose • Write ‘units’ or ‘International units’

• Always use ‘subcut’ and ‘subling’

What’s wrong with this?

Multiple routes prescribed, doses not equivalent

Routes of Administration • Do NOT prescribe multiple routes of administration

• For most medications oral and parenteral doses are NOT equivalent (e.g. furosemide, opioids)

• If a different route is required e.g. NBM patient, cease old order and write a new order

• Consider necessity and cost of parenteral medication • IV vs Oral Paracetamol ($$$)

Rewriting charts • Do not leave for night or weekend staff

• They are not familiar with the patient

• Medication Reconciliation! Check charts after you have finished to ensure you have transcribed correctly.

• Check carefully for omissions, duplications, transcription errors or inadvertently re-starting a ceased drug

• PRN chart must also be rewritten

Transcription Errors

• Amlodipine 200mg ordered instead of Amiodarone 200mg on rechart

Transcription Errors

• Cyclosporin 250mg PO BD recharted, instead of 25mg BD.

• High doses are used post transplantation (10-15mg/kg), so this was assumed to be correct and given to the patient.

Transcription Errors

• Hydralazine ordered on rechart, instead of hydrocortisone.

Transcription Errors

• Glimepiride should be 4mg

• Very common for strength of preceding drugs to be prescribed inadvertently

Tips for stat orders • Check for possible duplication on regular chart

• Don’t write ‘Stat’ – date the order and write the date and time it should be given

• Some once only orders are for the future – be clear about timing and date of dose

• Check that the nurse knows that you have written the stat order

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Telephone Orders

Telephone orders should never be used as a matter of convenience and only where the benefits outweigh the risk

2 nurses need to listen to and confirm the telephone order

Orders need to be signed within 24 hours by YOU

Not to be used for S8 medications

Notes for the National Inpatient Medication Chart (NIMC)…

• Number every chart so it is clear how many charts there are for each patient. Update the numbering if you add another chart.

• Aim to keep charts to a minimum to reduce risk of duplication, drug interactions and unintended omissions

Help us get it right…

• If a pharmacist, nurse or patient asks a question about your order, please listen and consider their concerns • It may be that your prescription is unusual • Explain your intention to other staff

Listen...

1. Is your order legible and clear?

2. Is it ambiguous?

3. Does it make sense clinically?

4. Your prescription is a form of communication to others

Resources for medicines information

• Downloading apps on your mobile device

• MIMS is free via CIAP • Pros and cons of

MIMs

• Micromedex, eTGs, upToDate

• CIAP

• Medical calculators • CrCl, BSA, IBW, BMI

• Beware of ‘Dr Google’

Don’t forget … Pharmacists are here to help!

• Page the ward pharmacist during working hours

• On-call pharmacy service available after hours • Contact via switchboard

• We are here to support and help you

Good luck!

Westmead Hospital NIMC business rules

Refer to this document for requirements of prescribing in WSLHD.

What is wrong with this?

No medication specified!

Items needing special attention!

• Combination packs with similar names: – Actonel EC Combi®

– Actonel EC Combi D®

Risedronate 35mg weekly

Calcium carbonate 1250mg daily every other day

Risedronate 35mg weekly

Calcium carbonate 2500mg + Cholecalciferol 22microgram – one multi-ingredient sachet every other day

Multiple options -Ensure prescription is clear

Method 1

Method 2