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Prescribing

Prescribing is one of the most dangerous areas for all clinicians and can be particularly hazardous for the inexperienced doctor. It is fraught with potential pitfalls ranging from transcription errors and inadvertent dosage mistakes to overlooked drug interactions, allergies and side effects, the consequences of which may be profound both for the patient and the prescriber.
Always document allergies and take care to double-check names, doses and frequency

It is imperative that you have a good knowledge of the pharmacology and the legislation surrounding drugs, and any protocols and controlled drug routines which apply within your workplace – if unsure, ask.

Always document allergies and take care to double-check names, doses and frequency ensuring that any prescription you write is legible. You should not feel pressured to do anything beyond your competence; always get a senior to do it.

If you are unsure about a prescription, or mishear on a ward round, always seek clarification, never guess. If a patient is admitted and there is any doubt regarding their current medication then consult the hospital pharmacists or the patient’s GP.

Survival tips

  • Prescriptions must be legible, dated and signed and must state your Medical Council number. They should clearly identify the patient, the drug, the dose, frequency and start/finish dates.
  • Doctors on the trainee specialist division of the Medical Council’s Register are not permitted to practise medicine outside of their training post and hence should not prescribe drugs other than in connection with that post.
  • Be aware of a patient’s drug allergies and be particularly careful when prescribing multiple medications in case the combination might cause side effects.
  • Good handovers require good leadership and communication. If you are asked to prescribe a drug or treatment regime with which you are not familiar you should ask for help.
  • Refer to the IMF.
  • Verbal prescriptions are only acceptable in emergency situations and should be written up at the first available opportunity. If a telephone prescription is necessary, you should make a note of the call in the patient’s notes and records and send a written prescription to the pharmacist without delay. Particular care should be taken that the correct drug is used.

Scenario

Dr S is on duty in the children’s ward. He has just admitted Patrick, a two-year-old child with a high temperature. He sits down to write his notes and takes the opportunity to ask one of the nurses to give Patrick 180mg of paracetamol, which would be appropriate to his weight. She asks for it to be prescribed, but Dr S insists that he will write it up as soon as he has completed his entry in the patient’s chart.

He points to Patrick’s bed: “it’s for Patrick, the new admission – the little boy at the end of the ward - you can not miss him”, he says. The nurse agrees reluctantly and goes to get the medicine and Dr S concentrates on writing in the chart. He looks up to see the nurse returning from the bed of another new patient who has just arrived on the ward and realises that the paracetamol has been given to the wrong patient, who is also called Patrick.

Dr S tells the family of the second child what has happened and explains that the paracetamol was not prescribed for their son. He apologises profusely and immediately calculates whether the paracetamol could cause an overdose.

Dr S makes sure his patient gets his paracetamol, which he properly prescribes. He also fills in an incident form after apologising to the nurse involved
Luckily he is a bigger child, and has not taken any paracetamol recently, so no harm has been done and Dr S is able to reassure his parents. Dr S makes sure his patient gets his paracetamol, which he properly prescribes. He also fills in an incident form after apologising to the nurse involved. They both agree that it was an easily preventable mistake and an incident from which they have each learned an important lesson. Later that day Dr S discusses the incident with his consultant, who reminds Dr S that he could have caused a patient to suffer avoidable harm but is supportive of the action he has taken to rectify the error that was made.