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  • Safe prescribing: An essential guide

Introduction to safe prescribing

'Prescribing’ is used to describe many related activities, including:

  • prescribing medicines, devices and dressings
  • supply of prescription only medicines
  • advising patients on the purchase of over the counter medicines and other remedies.

It may also be used to describe written information provided for patients (information prescriptions) or advice given.

Prescribing happens in a range of contexts, including face to face and remotely using telephone, online and video-link or other technological platforms. The principles of safe prescribing should apply in all of these situations, if it is not possible to meet the standards of safe prescribing through the mode of consultation then an alternative should be offered where possible.

The essential elements of safe prescribing include:

  • Careful assessment of the patient.
  • Identifying evidenced based treatment options.
  • Presenting options to the patient and reaching a shared decision.
  • Writing the prescription.
  • Arranging appropriate monitoring and review.

Doctors are by far the largest group of prescribers, who, along with dentists, are able to prescribe on registration. They have been joined by independent and supplementary prescribers from a range of other healthcare professions for example nurses, pharmacists and paramedics who are able to prescribe within their scope of practice once they have completed an approved education programme.

Doctors with full registration may prescribe all medicines, except those set out in Schedule 1 of the Misuse of Drugs Regulations 2001. Schedule 1 includes drugs not used medicinally such as hallucinogenic drugs (e.g. LSD), ecstasy-type substances and cannabis. A Home Office licence is generally required for their production, possession, or supply.

The Royal Pharmaceutical Society (RPS) has published a Prescribing Competency Framework that includes a common set of competencies that form the basis for prescribing, regardless of professional background.

The competencies have been developed to help healthcare professionals to be safe and effective prescribers, with the aim of supporting patients to get the best outcomes from their medicines.

The Competency Framework for all Prescribers was first published by the RPS in July 2016 and going forward, the RPS will continue to maintain and publish this framework for all regulators, professional bodies, education providers, prescribing professions and patients to use.

This competency framework sets out what good prescribing looks like. Prescribers are encouraged to refer to their own professional codes of conduct, standards and guidance alongside this framework including for example the guidance on good practice in prescribing issued by the General Medical Council (GMC).

It is important to be aware that the person who signs the prescription is the one who will be held accountable, should something go wrong, and so a prescriber must be satisfied that the prescription is right for the patient concerned and falls within the limits of their competence in prescribing. This is especially important to bear in mind when prescribing on the recommendation of someone else, like a specialist or another member of the healthcare team or when delegating the task.

Assessing the patient and identifying treatment options

Medicines should be prescribed only when necessary, and in all cases the benefit of administering the medicine should be considered in relation to the risk involved.

The prescriber should before reaching a decision undertake a full assessment of the patient and this will include gaining a clear understanding of the patients' symptoms, examination findings, test results, medical, and medication history including allergies and intolerances.

The risks and benefits to the patient of taking or not taking a medicine or treatment should be fully considered taking account of co-morbidities, existing medicines, allergies, intolerances, contraindications and quality of life impact.


Non-pharmacological as well as pharmacological treatment approaches should be considered. Non-pharmacological treatment approaches include no treatment, social prescribing and wellbeing or lifestyle changes.

It is important also to take into account other relevant patient factors and their potential impact on the choice and formulation of medicines, and their route of administration, for example the patient's ability to swallow, a disability, visual impairment, frailty, dexterity, religion and beliefs.

Before prescribing it is essential to be familiar with current guidance from the British National Formulary, including the use, side effects and contraindications of medicine prescribed.

An awareness of guidance relating to the clinical and cost-effectiveness of medicine prescribed is also important and this is available from NICE in England and Wales and from local commissioning bodies, who may have specific prescribing policies and guidance, that should be considered.

Prescribers are responsible for practising within their own scope of practice and competence, including delegating where appropriate, seeking support when required and using their professional knowledge, skills and judgement.

Reaching a shared decision

Patients should be fully informed about their condition and the reason for recommending the proposed treatment including the risks and benefits and rationale behind management options in a way the patient understands, so that they can make an informed choice

The patient should understand what they can expect in terms of improvement, symptoms to report, the need for any monitoring and review, and side effects that may occur – including interactions with other drugs, including over-the-counter medicines and alcohol. They should also be aware of reasonable alternative treatments and the option and implications of not receiving treatment.

The principle of informed consent applies as much to the prescribing of medication as it does to the performance of a surgical procedure.

It is important to discuss treatment options carefully with the patient to ensure that the patient is content to take the medicine as prescribed. In particular, the patient should be helped to distinguish the adverse effects of prescribed drugs from the effects of the medical disorder. When the beneficial effects of the medicine are likely to be delayed, the patient should be advised of this.

It would be appropriate to warn the patient of potential adverse effects, e.g. that driving and/or handling dangerous machinery would be contraindicated.

Sometimes, patients will ask for treatment or care that you don't think is in their clinical interests. In these situations, you should explore the reasons for their request, their understanding of what it would involve and their expectations about the likely outcome. This discussion will help you take account of the factors that are significant to the patient and assess whether the treatment or care could serve the patient's needs. If, after discussion, you still think the treatment or care would not serve the patient's needs, you should not provide or propose it. You should explain your reasons to the patient and explore other options that might be available, including their right to seek a second opinion.

Writing prescriptions

Computer-generated prescriptions are now common; however, when writing a prescription, there are some key points to remember:

  • use indelible ink
  • do not abbreviate drug names
  • do not use decimal places if it is not necessary
  • clearly state the drug, dose, strength, route, frequency and quantity
  • if amending the prescription, draw a line through the incorrect part and initial the change.

Prescriptions should be dated, and should include the full name and address of the patient. For patients under 12 years old, the patient’s age or date of birth should be included.

It is essential to check the correct dose of the medicine; this includes checking the strength, frequency and route. This is especially important in prescribing for children.

Blank prescription forms should be kept in secure conditions.

Prescriptions for controlled drugs have additional legal requirements and professional requirements which should be adhered to.

More information on controlled drugs and drug dependence.

 

A clear record should be made in the patient’s notes of all medicines prescribed.

It is important to ensure that the patient:

  • is not allergic to the proposed medication
  • is not taking any medication (prescription, over-the-counter or alternative medicine) which may interact with the proposed medication
  • does not have an illness that may be exacerbated by the medication.

More information on writing prescriptions.

Read more from Medical Protection on: Prescribing

Monitoring and follow-up arrangements

Appropriate arrangements for follow-up and monitoring should be agreed with the patient. Patients need to know under what circumstances they need to come back, and what the consequences of failing to attend for review could be.

If you are not the patient’s regular medical professional, you should ask for the patient’s consent to share information with their GP when the episode of care is completed.

Prescribing on the recommendation of a specialist

It is common for general practitioners to be asked to continue prescribing a medication started in the secondary care setting, and it is important to ensure that the following information is available before prescribing the medication:

  • Aim of treatment
  • Mechanism of action
  • Dose and frequency
  • Risks and benefits
  • Any monitoring that is required
  • Potential side effects
  • What the patient has been told.

It is important that healthcare professionals are clear as to who will be undertaking any required monitoring and review of medication. In many areas, Shared Care Guidelines have been established to aid communication and reduce the risk of errors occurring.

It is also important to be familiar with the “Traffic Light System” which classifies drugs and their suitability for shared care arrangements. This can have local variation and should be reviewed regularly.

Legal responsibility for prescribing lies with the individual who signs the prescription.

Remote prescribing

When prescribing or proposing medicines and treatments remotely appropriate safeguards must be in place to support safe prescribing. Relevant safeguards include robust identity checks to make sure medicines are prescribed to the right person. If you are not the regular medical professional, check to make sure the patient has given consent for their regular prescriber to be contacted about their prescription, making sure all relevant information about the prescription is shared with the patient’s GP or added to the primary care record.

Patients should be provided with the names, roles and contact details of key people who will be involved in their care, as well as advice about who they can contact if they have any questions or concerns.

Pharmacies may not dispense some categories of medicine if they are prescribed remotely, unless certain safeguards are met.

Read guidance for registered pharmacies on providing pharmacy services at a distance, including on the internet

A physical examination of patients must take place before prescribing non-surgical cosmetic medicines, such as Botox and other injectable cosmetic medicines and so they cannot be prescribed remotely.

If you are asked to prescribe medicine to patients remotely or overseas as well as the general advice on safe prescribing and remote prescribing it is important to consider, differences in a product’s licensed name, indications and recommended dosage. Whether you have adequate insurance or indemnity arrangements in place to cover your practice in all relevant countries, the need to be registered with multiple regulatory bodies, including in the country you are based, in the country the patient is based, and in the country where the prescribed medicines are to be dispensed.

UK and overseas legal requirements as well as relevant guidance on import and export for safe delivery, including advice from the MHRA must be followed.

Unlicensed medicines

Medicines should usually be prescribed in accordance with the terms of their licence. However, unlicensed medicines may be appropriate for an individual patient to meet the specific needs of the patient.

When prescribing or providing an unlicensed medicine it is important to be satisfied that there is sufficient evidence or experience of using the medicine to demonstrate its safety and efficacy. A clear, accurate and legible record of the medicine prescribed and, the reasons for prescribing an unlicensed medicine should be made.

Unlicensed medicine describes medicines, which are used outside the terms of their UK licence or that have no licence for use. Unlicensed medicines are commonly used in some areas of medicine, such as in paediatrics, psychiatry and palliative care.

Some medicines are routinely used outside the terms of their licence, for example in treating children. In these situations, and in emergencies or where there is no realistic alternative treatment and such information is likely to cause distress, it may not be practical or necessary to draw attention to the licence.

In all other cases a patient should generally be informed of the unlicenced prescription, why the medicine is not licensed for the proposed use or patient population and the reasons for choosing to prescribe the medicine.

Self-prescribing, and prescribing for friends and family

Where possible it is best to avoid prescribing for yourself or anyone you have a close personal relationship with.

If you do prescribe any medicine for yourself or someone close to you, you must make a clear record at the same time or as soon as possible afterwards; the record should include your relationship to the patient, where relevant, and the reason it was necessary for you to prescribe. You should also, with the patient's consent, inform their GP or usual medical care provider of the prescription.

Read: Prescribing and advising family and friends

Special groups and situations

The elderly, children, pregnant women and men and women “trying” for a baby all require special consideration, as well as individuals with particular medical conditions like kidney or liver impairment.

Read more guidance on prescribing.

Patient safety incidents

Early, routine reporting of adverse reactions, incidents and near misses involving medicines and devices can make sure performance and systems issues are investigated, problems rectified and lessons learned. Reports of incidents should be made in accordance with an employer or contracting body's local clinical governance procedures and the Yellow Card Scheme may be used to inform the MHRA about serious suspected adverse reactions to a medicines or products.

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