As soon as you get your shiny certificate from the GMC and those magic letters 'MBChB' after your name, you can legally prescribe medications for patients in hospital. Almost as soon as you walk onto the ward on your first day the nurses will be asking you to review Mr X's pain relief or prescribe an insulin sliding scale for Bed 5. To save your red face whilst you whisper "Erm, how do I write up paracetamol again?", and more importantly to ensure you and your patients remain safe, make sure you swot up on the essentials that every FY1 should know about prescribing.
The basic drug chart has three sections:
Every hospital/trust uses a slightly different chart unique to that hospital. In addition, it's likely there will be other sections or separate charts for prescribing certain drugs such as fluids, oxygen, warfarin, insulin, blood products and some antibiotics (e.g. vancomycin).
It's a good idea to familiarise yourself with your hospital's charts before you start work (such as during your shadowing period if your hospital requires one) - this will save you getting into a flap when your consultant asks you to look at the drug chart on the first ward round.
You must write clearly in black pen and use block capitals when prescribing. This is important so that others can easily read your prescription and so the patient gets given the correct medication - very important!
Also it makes the lives of your colleagues much easier when writing discharge prescriptions if they can actually read the chart!
Consider the example below;
Does that say Omeprazole or Oromorph? Someone glancing at the chart quickly might not be able to easily read it, and confusing drugs such as these could lead to serious consequences.
Look at this prescription;
Does that say 30 units or 300 units? A 'U' and a '0' can easily be mistaken for each other. Similarly a 'µ' could be confused with a '0' or a 'U'.
Such mistakes could result in serious prescribing errors. Consider the above prescription - if 300 units of insulin were given instead of 30, the consequences would most likely be fatal for the patient. One would hope that the individual administering the insulin would be experienced enough to realise 300 units was a mistake and clarify the prescription with you, but the responsibility for any adverse incidents that arose would lie solely with you as the prescriber.
Avoid confusion and write the words in full, block capitals.
Once the patent has been lifted from a particular drug, different pharmaceutical companies are free to manufacture it under varying names.
For example Simvastatin, a very commonly prescribed medication, is marketed under the brands Ranzolant®, Simvador® and Zocor®. The pharmacy at your hospital/GP is only likely to stock one of these brands.
Therefore it's important when prescribing medications to use generic names (Simvastatin in this case), as far as possible so that it's clear exactly which medications you want prescribing and to avoid limiting to a particular brand. This keeps cost down too.
Always make sure you sign each prescription and clearly print your name and bleep/contact number, so you can be contacted with any queries if necessary.
A prescription isn't actually valid without these three things, so please don't forget them!
Be sensible and use your common sense when prescribing. Think about how you want to give the medications (oral, IM, IV, S/C?) and when (morning, lunchtime, evening? with or after meals?). You need to specify these points on your prescription - usually there will be a box for 'route' and you'll circle or tick the times you want.
A common example is prescribing anti-emetics for patients. In this instance, it wouldn't be very sensible just prescribing the medication PO (per os - in other words, orally). If you were feeling very sick, would you want to be taking a load of tablets? Not likely, so instead think about alternative routes - intra-venous (but do they have venous access?), intra-muscular (IM), or transdermally.
Remember you can write multiple routes (e.g PO/IV/IM) to give the nursing staff some flexibility. However, be aware that some drugs have altered bioavailabilities when administered through different routes, so dosings may vary.
Other times you should think carefully about delivery of medications to patients who are nil by mouth, or have an unsafe swallow. Again, in this case it would be inappropriate to give medications orally, so you may need to explore other options. Look in the BNF or speak to your Pharmacist for advice.
Timings of medications are important - particularly for pain relief. For patients on multiple analgesics you should always think about trying to deliver a constant baseline of pain reflief, as opposed to a pattern fluctuating between peaks and troughs.
For example, for a patient taking regular paracetamol (1g, four times a day) and ibuprofen (400mg, three times a day), it makes sense to prescribe the ibuprofen between the paracetamol doses. The patient's analgesic control would therefore look like this;
Obviously, the type of analgesia is dependent on the patient's pain level and you should refer to the WHO pain ladder for guidance. The BNF also has a helpful section on prescribing regimes of modified release and short-acting opiates.
You should document all allergies and intolerances clearly on the drug chart as well as in the medical notes, so that all medications can be cross-checked easily. There is usually a section on the drug chart for this.
Also, document the nature of the allergy; is the patient experiencing a true drug allergy or just side effects of the medication? The classic example would be gastro-intestinal upsst with antibiotics - this is often mistaken as an allergy by patients. However, this should still be documented on the drug chart, as in most cases an alternative drug can be used.
Remember to ask about different allergies other than medication, e.g. latex, plaster, tape or food substances. These should also be listed on the drug chart and in the patient's medical notes.
As an FY1, a good proportion of your time will be spent re-writing charts which are full and have run out of space. Although this may seem like a tedious task, it is important and it's actually illegal for nursing staff to administer medications to patients if they cannot record it in a free column on the drug chart.
The tempation is to just copy the information from the old chart onto the new one, without really thinking about it. However, you must remember that it is your signature on the new prescription, so you should ensure what you are prescribing is accurate and safe. With any prescription you should know what the drug does and why it's being prescribed for your patient. This is not only to ensure safe clinical practice but is also useful for your own education.
As mentioned before, hospitals will often have several different types of charts for you to prescribe things like Insulin, Warfarin, some antibotics (e.g Vancomycin), syringe drivers and PCAS. You should always cross reference these on the main drug chart, so that it's clear these charts are in use.
You can do this simply if you set it out like the example below;
Also, make sure you fill in the other charts accurately and correctly - they are prescriptions as well so the same rules apply with writing clearly, printing your name and contact details, adding allergy status etc.
This is probably the most important point of all. If you have ANY doubt about what or how to prescribe - always check, double check, and triple check!
There are plenty of resources which you can access. Every clinical area should have at least one up to date BNF, where you can find information (such as indication for use, interactions, side effects etc) and dosing guidance for all medications. There are several appendix sections in the back pertaining to prescribing in 'special' circumstances such as liver disease, renal impairment, pregnancy and breast feeding. Also remember that there is a seperate paediatric BNF for prescribing in children. Alternatively the BNF has an online system that is free for students.
I recommend getting your hands on a copy of the BNF before you start work so you can get used to navigating your way around it, and use it to look up various medications. Ask around - most departments will have some old copies lying around which they will be happy to give you.
Another invaluable resource to an FY1 doctor is the ward pharmacist. Make friends with them on your first day and they will be happy to help you with any prescribing queries. Don't forget out of hours there is always an on-call pharmacist just a phone call away too.
Prescribing may seem daunting, especially when you first start work as a doctor, but there's no need for it to be.
If you act sensibly, follow the tips above and ask for help when needed, you'll be able to prescribe medications which are effective and safe for your patients.
It's worth spending a short time before you start your first job reminding yourself of the standard drugs prescribed for analgesia, nausea/vomiting, constipation and other day-to-day conditions encountered on the wards. Fastbleep covers these drugs in other articles available on the site.
Remember - it's your name on the prescription and so your legal responsibility to ensure it's right!
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