Good prescribing practice - General advice

This guideline provides brief guidance on good prescribing practice. See the NHSAAA Code of Practice for Medicines Governance Policies: Prescribing on Admission to Hospital and Prescribing - Ethics, Standards and General Principles on AthenA for more details (links only active if accessing via NHS network).

On admission - as soon as possible (within 24 hours)

• Obtain a complete and accurate medication history using a minimum of two information sources, and record this in the medical notes. The default information sources should be the Emergency Care Summary (ECS) and the patient where possible. Other sources of information include: relative/carer, GP Practice/referral letter, nursing home records, community pharmacy, patient's own drugs or recent immediate discharge letters (IDLs). Always check the 'last updated' date on any source of information you use to ensure it is current and relevant.
• Resolve any discrepancies between the information sources and document your decisions (stop / amend / withhold medication) in the medical notes. 
• See Assessing Medicines on Admission in Acute Patients for general principles to consider for each medicine the patient is taking on admission.

During admission - before prescribing:

• 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 ability to handle the medicine (e.g. renal or hepatic impairment, interactions, weight), presence of or risk factors for QT prolongation, formulary status of the medicine, ability to take oral medicines, compliance issues.
• Continually review the need for each medicine 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) guideline).
• Monitor patient for potential and actual adverse reactions.
• Clearly document any medication changes and the reason in the appropriate location of the patient's medical records (e.g. medicines prescription chart, Hospital Electronic Prescribing and Medicines Administration (HEPMA) system, medical notes).

Medication Incident Reporting

• A medication incident is an error, adverse event or near-miss 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 NHSAAA AthenA (link only active if accessing via NHS network), to report all incidents. Incidents should be managed and investigated as per NHSAAA Code of Practice for Medicines Governance - Reporting Medication Incidents Policy (link only active if accessing via NHS network) and the Adverse Events Policy available on NHSAAA AthenA.

Minimising medication incidents 

On the medicines prescription chart ensure:

• Medicines are written legibly and in full, using generic medicine names wherever possible, unless there are 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.
• Medicines prescribed on a separate prescription chart e.g. warfarin, insulin, gentamicin are also prescribed on the medicines prescription chart 'as charted' with reference to the separate chart.
• The frequency of the medicine is clear e.g. if once weekly then strike out the 6 days when the medicine is not to be administered. If a medicine is to be taken 'when required' then specify the maximum frequency not to be exceeded.
• For courses of treatment, the duration or review date is stated e.g. antibiotics, steroids.
• 'Micrograms', 'nanograms', 'units' are written in full e.g. 10U insulin could be read as 100 units 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 medicine is clearly stated.
• Sign and date all prescriptions - if a prescription chart is re-written then the date against each medicine entry should be the date the medicine was originally prescribed, not when the prescription was re-written.

HEPMA prescribing:

The basic principles stated above apply to HEPMA prescribing with the following additions (see NHSAAA Code of Practice for Medicines Governance: Prescribing for Adult Inpatients for more details - link only active if accessing via NHS network):

• Always check you have selected the right medication. The confirmation screen allows you to review what you have done before completing.
• Decision support only covers interactions and duplicate therapeutic products. Always check dosing is appropriate. HEPMA does not dose check.

On discharge

• As the discharge prescription (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 NHSAAA Code of Practice for Medicines Governance - Prescribing on Hospital Discharge on AthenA (link only active if accessing via NHS network). 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 the IDL 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.

Compliance aids

These are used widely but may not always be suitable or appropriate for the patient. Assessing a patient for a compliance aid may be more appropriate when carried out after discharge to their home environment. If a new compliance aid needs to be set up prior to discharge, a member of the ward clinical team needs to discuss the suitability with the patient / patient's family / carer and identify if the patient's usual community pharmacy, or an alternative community pharmacy, would be able to continue this service long-term. This should be carried out at least 48 hours prior to discharge.