INTRODUCTION TO PRESCRIBING

Senior CycIe 1
Introduction lecture (PRE-CLASS READING)
Prescribing workshop
LEARNING OUTCOMES

• At the end of this workshop, you should be able to:

• List the legal requirements for a prescription

• Write a legal prescription for non-controlled medications
• Write a legal prescription for controlled drugs
• Describe law surrounding repeat prescriptions
• Describe the law surrounding Emergency Supply of prescription medications
• Cancel/discontinue a prescription
• Choose the correct prescription type (inpatient, discharge, controlled drug, etc.)
• Choose and prescribe the correct medications for common acute and chronic conditions
• Write a prescription for the following:
 Oral, intravenous and transdermal analgesics including controlled drugs
 Anti-emetics
 Antibiotics: Choose appropriate antibiotics for the management of community and hospital
acquired pneumonia, urinary tract infection and urosepsis and cellulitis.
 Fluids
 Steroids
 Anticoagulation
 Oxygen
 Medications used in anaphylaxis
 Medications used in common acute and chronic medical conditions including deep vein
thrombosis, pulmonary embolism, pulmonary oedema.
• Calculate appropriate medication dosing and administration including weight based doses, body
surface area dosing.
• Identify prescribing error and illustrate how to correct errors on a prescription kardex
• What is a drug?

A medicine or other substance which has a physiological effect when ingested or otherwise introduced
into the body.

• Why are Medications prescribed?

They are prescribed to

1. Cure disease
2. Reduce/eliminate symptoms
3. Arrest/slow the disease process
4. Prevent disease/symptoms
• What is a prescription?
A prescription is a written order by a medical doctor (or dentist/certain nurse practitioners) to a
pharmacist in the form of medication instructions for an individual patient.
SUCCESSFUL PRESCRIBING LEADS TO...

Right Patient

Right Medicine
Right Route

Every

Time!!

Right Time Right Dose

Building a safer NHS for patients: improving medication safety

 THE MEDICINAL PRODUCTS (PRESCRIPTION AND
CONTROL OF SUPPLY) REGULATIONS 2003
Introduction to the Regulations
The effects of the introduction of the regulations are:
• To restrict the sale of scheduled prescription medicines for human use to supply on a prescription-only basis
• To provide that certain medicines exempt from prescription-control may only be supplied under the supervision of a
pharmacist
• To allow emergency supply of prescription-only medicines in certain circumstances
• To regulate supplies of prescription-only medicines by pharmacists
• To regulate recording of supplies by pharmacists
• To regulate labelling of all dispensed medicines
• To create a category of medicines that may only be dispensed in hospitals (S1C)
• To prohibit the keeping for sale or supply of medicines after its expiry date
• To prohibit supply of medicines by mail order
• To allow registered nurses to prescribe in certain circumstances

Department of Medicine
RCSI
LEGAL REQUIREMENTS OF A PRESCRIPTION

• Must be issued by a registered medical practitioner, dentist or nurse

• May be dispensed if it is written within the EU. Prescriptions from non-EU countries may not be
dispensed in Ireland. (Prescriptions for controlled drugs must be written within the state)
• Prescriptions must comply with the legal requirements outlined below and an appropriate record must
be made:
– Be in ink
– Be signed by the prescriber with his/her usual signature
– Be dated by the prescriber
– Except in the case of a health prescription (GMS), specify the prescriber's address
– Specify the patient's name and address
– Specify the patient's age if under 12 years of age
– Clearly indicate the name of the person issuing it and state whether he/she is a registered medical practitioner, a
registered dentist, a registered nurse (If a registered nurse issues the prescription, his/her registration number)

Department of Medicine
RCSI
FURTHER INFO

• The prescription must only be dispensed if it is 'an original' as issued

by the prescriber. This means that faxes, emails etc. are not
considered legal prescriptions. The only exception is a GMS three-
monthly repeat prescription where three months are prescribed at
once by creating two carbon copies of the original prescription. (Note:
Repeat by 2 must be written on the top copy in order for the
prescription to be legally repeated)
• A prescription for a medicinal product (except a Controlled drug in
Schedule 2 or 3 or for isotretinoin) can be dispensed up to six months
after the date it is written, or the intended duration of treatment,
irrespective of the number of repeats indicated by the prescriber.
• If one of these items is missing, the prescription may still be
dispensed, where the pharmacist exercises due care and diligence,
and is satisfied that it is safe to do so.

Department of Medicine
RCSI
FURTHER INFO

• The prescription must only be dispensed if it is 'an original' as issued

by the prescriber. This means that faxes, emails etc. are not
considered legal prescriptions. The only exception is a GMS three-
monthly repeat prescription where three months are prescribed at
once by creating two carbon copies of the original prescription. (Note:
Repeat by 2 must be written on the top copy in order for the
prescription to be legally repeated)
• A prescription for a medicinal product (except a Controlled drug in
Schedule 2 or 3 or for isotretinoin) can be dispensed up to six months
after the date it is written, or the intended duration of treatment,
irrespective of the number of repeats indicated by the prescriber.
• If one of these items is missing, the prescription may still be
dispensed, where the pharmacist exercises due care and diligence,
and is satisfied that it is safe to do so.

Department of Medicine
RCSI
 PRESCRIBING CHECKLIST

• ? Is the drug needed

• ? Is it the best choice of drug for the patient
• ? Is the dose correct
• ? Is the drug likely to interact with other medication
• ? Is the drug likely to interact with other diseases
• ? Is the drug regimen as simple as possible
PRESCRIBING CHECKLIST

• ? Is the formulation suitable for the patient

• ? Does the patient understand how to take
the drug
• ? How long is the medication to be
continued for
• ? Will the drug require monitoring
• ? Cost effective
PRINCIPLES OF GOOD PRESCRIBING

• State patient details clearly (name, address, date of birth, age

(children/elderly).
• Take account of any allergies and complete relevant paperwork.
• Use generic drug names
• State drug, dose, strength, route and frequency
PRINCIPLES OF GOOD PRESCRIBING

• Avoid abbreviations
• Avoid multiple route prescribing (i.e.
im/sc/po)
• State dose as grams, mg, micrograms.
• Make administration of once weekly
drugs clear
ABBREVIATIONS

• bd. - bis die (twice daily)

• od. - omne die (once daily)
• Nocte - nightly
• tds - ter die sumendus (to be taken three times daily)
• tid - ter in die (three times daily)
• prn - pro re nata (when required)
• qds - quarter die sumendus (to be taken four times daily)
ROUTES OF ADMINISTRATION

• Oral
What formulations are
• Buccal/Sublingual
available?
• Transdermal
• Rectal
• Vaginal
• Injections
– Intramuscular, intravenous, subcutaneous most
common
• Intra-articular etc.
• Inhalation/Intranasal
• Topical
• Ophthalmic
• Implant
These are just some common examples, there are several more.
EXAMPLE OF PRESCRIPTION
Dr A Kashan MD
Ink 123 St Stephen’s Green
Tel: 014022482
Doctor’s name
01/10/12
Doctor’s address

Date Judy Stuart

63 Main Street
Ashfield
Patient’s name Trimethoprim 200mg BD PO x 3/7 (or Trimethoprim
200mg twice daily, orally for three days)
Patient’s address
Paracetamol 0.5 - 1g QID PO PRN x 5/7 (or Paracetamol
1g fours times daily as required for five days)
Age (if < 12)
Mitte 30 tablets

Signed
(MCN 12345)

Doctor’s MCRN
Hospital prescription: Fill in the
blanks…

Ward

DOB and age

Record if >1 kardex

being used
Date kardex commenced

Allergies – include the

reaction to the drug

Sign to confirm
allergy hx taken
 EXAMPLE OF HOSPITAL
PRESCRIPTION
Drug start date
One box per day
Generic drug name

Frequency

Dose

Route Time of admin

Bleep number and MCRN
CEASING MEDICATIONS

Physically block further

administration

Prevent transcription errors Sign and date, state reason

but still legible for records for ceasing
Discharge Prescription

Bleep number and MCRN

INTRODUCTION TO SCHEDULES

These Regulations set out the classes of medicine that must be supplied, only on foot of a prescription.
This information is available in 'the Schedules' to the Regulations.
• All medicines are categorised into one of seven schedules of medicines depending upon:

– The need for a prescription

– The outlet from where the medicine can be sold
– The quantity, strength & form by which it can be sold

Department of Medicine
RCSI
SCHEDULE 1
Schedule 1: all medications under prescription control
• Part A (Non-renewable) –
– A product which can be issues by a pharmacist on the foot of a valid prescription issued by a
qualified, registered practitioner.
– Can only be issued once, without repeats. Once dispensed, the pharmacist retains the script
– If intervals are specified but the number of repeats are not, the total prescription may be
repeated twice. In this case, the prescription is returned to the patient.
– Where the number of repeats is specified but the intervals are not, the prescription may be
repeated at such intervals as the pharmacist deems appropriate.
• Part B (Renewable) –
– A product which can be issues by a pharmacist on the foot of a valid prescription issued by a
qualified, registered practitioner.
– A prescription for an S1B item may be legally repeated at appropriate intervals for up to six
months after the date it is written.
– Where intervals are specified may be dispensed for up to 6 months at appropriate intervals
having regard to the dosage rate and quantity specified, unless the prescriber directs otherwise
in writing.
– Where the number of repeats only is specified, the prescription may be repeated at such
intervals as the pharmacist deems appropriate, for up to six months.

Department of Medicine
RCSI
EXAMPLES

* Repeat only if prescription specifically worded

** except insulin (in schedule S1B)
***flunitrazepam/temazapam subject to prescription writing requirements under Misuse of
Drugs Regulations as they are CD3- see next slide
***other benzodiazepines are generally also scheduled as CD4 drugs
CONTROLLED DRUGS

For the purpose of the Regulations, controlled drugs are classified into five schedules with different
controls applying to each:

1. (CD1) Little therapeutic value, high abuse potential. Special license required. In practice limited to
scientific or forensic practice. e.g. cannabis, coca leaf
2. (CD2) Therapeutic value, but also abuse potential. CD prescription requirements apply. e.g. morphine
3. (CD3) Less stringent controls overall, but CD prescription requirements apply. e.g. temazepam
4. (CD4) Control is minimal e.g. diazepam
5. (CD5) Exempt from most restrictions e.g codeine linctus (containing not more than 10mg of
dihydrocodeine base per unit dose)
PRESCRIPTIONS FOR CONTROLLED DRUGS
Prescriptions for CD2 or CD3 drugs must:
1 - be in ink
2 - be signed by the prescriber with his usual signature
3 - be dated by the prescriber
4 - clearly indicate the prescriber's address (unless GMS). (Must be within the state)
5 - clearly indicate the prescriber's name and state whether the person is a registered doctor,
dentist, veterinary surgeon or nurse
6 - specify a telephone number at which the prescriber may be contacted
7 - have the following information in the prescriber's own handwriting:
Name and address of patient
The name of the drug
The form of the drug
The strength of the drug
The dose of the drug
The total quantity to be expressed in words and figures
8 – If the prescription is for instalments, the quantity and number of instalments and intervals
between them.
OTHER LEGAL REQUIREMENTS

Instalments
• Controlled drug prescriptions may not be repeated, but may be
dispensed in instalments.
• In the case of a prescription to be dispensed by instalments, the 1st
instalment is not dispensed later than 14 days from the date on the
prescription and no instalment is dispensed later than 2 months after that
date.
Hospitals
• In public hospitals or nursing homes, prescriptions for controlled drugs
may be written on the patient's bed card (Kardex) or case sheets and this
will be acceptable. A separate prescription is not required.
• In private hospitals this exemption does not apply and prescriptions must
meet requirements above.
MISUSE OF DRUGS (SUPERVISION OF PRESCRIPTION AND SUPPLY OF
METHADONE)REGULATIONS 1998
Methadone is at present the drug of choice in Ireland for the management of opiate
dependency (it is a CD2 drug):
• All patients must be registered on the Central Treatment List before being
prescribed methadone. This is a confidential list, accessible to only doctors and
pharmacists.
• Each registered patient is assigned a doctor and a pharmacist.
• A doctor must undergo special training before registering to prescribe methadone
Drug Treatment Cards (DTC)
• Health board issues every person participating in a methadone treatment
programme with a DTC which is valid for one year.
• The pharmacist must see this card before they may issue any methadone
• Methadone may only be prescribed on a special prescription form
• Pharmacists may only dispense methadone
– On foot of a valid prescription
– To a person holding a valid DTC
– Be vigilant to ensure DTC has not expired
NOTE:
2 weeks maximum
for any controlled
drug prescription!
WHEN PRESCRIBING OPIOIDS, CONSIDER:

Nausea – experienced in 25% of patients on opioids:

• Prokinetic – metoclopramide
• Serotonin antagonist – ondansetron

Constipation
• Osmotic – lactulose, polyethyleneglycol
• Stimulant – bisacodyl, senna

CNS adverse effects

Pruritus
• Cetirizine
EMERGENCY SUPPLY

• In certain instances a patient may need access to a medicine restricted to prescription control when
they do not have a prescription
• The legislation provides for 'emergency supply' of medicines in certain defined circumstances
• The prescriber may request that the pharmacist supplies a medicine subject to prescription control if:
– A registered medical practitioner, registered dentist or registered nurse by way of emergency is unable to furnish a
prescription immediately.
– The prescriber has undertaken to furnish a prescription within 72 hours.
– The medicine is supplied in accordance with the directions of the prescriber.
– The product is not a controlled drug in Schedule 1, 2, 3 or 4 to the Misuse of Drugs Regulations 1988-2007
• Except methylphenobarbitone, phenobarbitone, or phenobarbitone sodium for the treatment of epilepsy

Department of Medicine
RCSI
EMERGENCY SUPPLY

In some circumstances, a patient may request a medicine subject to

prescription control. The pharmacist may dispense this if:
• The pharmacist has interviewed the patient and is satisfied that
– There is an immediate need for the product, and that it is impracticable under the
circumstances to obtain a prescription without undue delay
– The patient has been prescribed the treatment on a previous occasion by a registered
medical practitioner, registered dentist or registered nurse.
– The dose can be safely specified
– No greater quantity than will provide five days treatment is supplied, except if the product
is
• An aerosol for the relief of asthma, a proprietary ointment or cream, in which case the
smallest container authorised shall be supplied
• An antibiotic for oral administration in liquid form, and the smallest quantity that will
provide a full course of treatment is supplied.
• An oral contraceptive and a quantity sufficient for a full cycle is dispensed.
• The product is not a controlled drug in Schedule 1, 2, 3 or 4 to the Misuse of Drugs
Regulations 1988-2007
– Except methylphenobarbitone, phenobarbitone, or phenobarbitone sodium for the
treatment of epilepsy
PRESCRIBING ERRORS
Common sources of errors:
• Wrong drug – esp Sound Alike Look Alike Drugs - SALAD
• Wrong dose
• Inappropriate Units – always write g, mg, micrograms (never µg), units
(never IU or U)
• Poor/illegible prescriptions
• Failure to take account of drug interactions
• Omission
• Wrong route/multiple routes (IV/SC?PO)
• Calculation errors (important in Paediatrics)
• Poor cross referencing between charts
• Infusions with not enough details of diluent, rate etc.
• Once weekly drugs – make this very clear, esp methotrexate
• Any drugs given at long intervals – fortnightly, every 3 weeks
• Multiple dose changes
 PRESCRIBING ERRORS

• Transcription errors, failure to communicate essential information, and the use of drugs or doses
inappropriate for the individual patient are considered prescribing errors.
• Is deviations from policies or guidelines a prescribing error? –Not always, there are exceptions.
PRESCRIBING ERRORS
UNCLEAR WRITING
DRUG CALCULATION AND CALCULATION ERRORS
• Calculations must be carried out before prescribing some medicines
Some examples include
o Weight-based dosing
o Body Surface Area
o Calculation of units of dosage form prescribed
o Converting Units of weight and volume
o Calculating concentrations
o Strength of drugs in ratios
o Calculating IV Drug Infusions

A helpful website/guide that runs through case examples:

http://www.baxterhealthcare.co.uk/downloads/healthcare_professionals/therapies/pharmacy_services/
ps_calc_guide.pdf

• Remember
– A single calculation error can be fatal (especially if parenteral drug/insulin etc.)
– Always take extreme care and get calculation double-checked by a colleague if possible (or pharmacist- generally
used to carrying out calculations frequently)
WEIGHT-BASED DOSES

• Common in
paediatrics/intravenous RCSI Hospital
York St.
medicines Dublin 2
• Usually expressed in mg/kg
• Caution should be taken to
Date: 12/1/13
ensure the weight is calculated
Patient: MV
or estimated accurately. Ward: Intensive Care Unit
Age: 12 years
• Examples Weight: 60kgs
• An intravenous solution is prepared Rx
that contains aminophylline Aminophylline 700micrograms/kg/hr
250mg/500ml. At what rate (ml/hr) Signed Dr. M. Moon(mcrn 12345)
should this be infused to provide
MV with the prescribed
maintenance dose?
BODY SURFACE AREA

• Used for cytotoxics and in paediatrics

• E.g. doxorubicin, temozolamide
• Can be estimated using formula/nomogram
When In Doubt…………………………

Your Best Friend

• Workshop 2 …..

Prescribing: Do it yourself:
Need to be able to prescribe medications including
-Analgesia including controlled drugs
-Anti-emetics
-Antibiotics
-Insulin
-IV Fluids
-Anticoagulation
-Oxygen

Write up a hospital kardex based on patients medication list

Calculating Drugs based on weight and body surface Area
QUESTION 1

Write a prescription for pantoprazole for the following inpatient:

Patrick Dolan, Date of birth: 15/08/1933

23 Main street
Naas
Co. Kildare
MRN: 409879

He is starting this medication for mild gastro oesophageal reflux disease. He is on a normal diet. He is
allergic to clarithromycin (experienced rash and dyspnoea when he last took this) and has no other
comorbidities.
He was admitted to St. Anne’s ward on 12-01-2012, under Professor Walsh. You can use your own name
and bleep number 123. He weights 75 Kg.
QUESTION 2

Write a discharge prescription for Oxycontin (oxycodone) for the following patient:

Judy Maitland, Date of birth: 5/4/42

23 Main street
Naas
Co. Kildare
MRN: 409879

She will require a week’s supply of Oxycontin (oxycodone) 10mg BD. She is on normal diet. She has no
allergies and no other comorbidities.
She is a patient of Professor Donnelly.
QUESTION 3
Write a prescription for a week’s supply of regular paracetamol and ibuprofen for
the following inpatient:

Patrick Dolan, Date of birth: 15/08/1933

23 Main street
Naas
Co. Kildare
MRN: 409879

He is day 0 post appendectomy. He is on normal diet. He is allergic to

clarithromycin (experienced rash and dyspnoea when he last took this) and has
no other comorbidities.
He was admitted to St. Anne’s ward on 12-01-2012, under Professor Walsh. You
can use your own name and bleep number 123. He weights 75 Kg.
You may write this prescription on the same kardex sheet as question 1.
QUESTION 4
Write a prescription for insulin (levemir 20 units nocte, actrapid 6 units three times
per day with meals) for the following inpatient:

Patrick Dolan, Date of birth: 15/08/1933

23 Main street
Naas
Co. Kildare
MRN: 409879
He is on normal diet. He is allergic to clarithromycin (experienced rash and
dyspnoea when he last took this) and has no other comorbidities.
He was admitted to St. Anne’s ward on 12-01-2012, under Professor Walsh. You
can use your own name and bleep number 123. He weights 75 Kg.
You may write this prescription on the same kardex sheet as questions 1 and 2.
You may prescribe these medications by their trade names.
QUESTION 5

E.g. Mr. L is 1.74m tall, weighs 72kgs and is being prescribed Temodal®
(temozolomide) capsules (monotherapy phase). The recommended dose is
150mg/m2 for 5 days followed by 23 days without treatment. Using the above
equation, what daily dose would you prescribe?
RELATIONSHIP BETWEEN DOCTORS AND INDUSTRY
• Doctors cannot:
– Accept gifts from pharmaceutical companies – even small, cheap items
can be used to influence doctor’s prescribing practices
– Accept hospitality outside of a scientific/promotional event
– Use sponsored promotional meetings as their sole means of learning
about new or existing drugs/medical devices
– Accept payment from a sales rep for agreeing to meet with them
– Allow their work to be influenced by sponsorship or and relationship
with industry

• Doctors can:
– Accept hospitality at scientific/promotional event
– Accept reasonable fees for work done under a contractual agreement
– Attend sponsored meetings to learn of drugs/medical devices
• More cases to follow in Prescribing workshop….
 THANK YOU!

ANY QUESTIONS?