The safe prescribing of high-risk drugs is implemented via individually designed templates for such drugs. These templates are short, concise and as per NICE recommendations and reviewed every 12 months to acknowledge any changes as per NICE. Following are the relevant NICE guidance, clinical guidance, key therapeutic topics and quality statements.
- NG5, KTT6 and TA77 for Hypnotics prescribing
- NG5, NG46, KTT21 and KTT24 for Controlled drugs prescribing
- NG5, NG100 and QS33 for various DMARDs prescribing in primary care
- NG5, CG180, KTT16, TA245, TA256, TA275, TA287, TA335, TA355, TA354, TA157, TA249, TA327 for NOACs prescribing
- NG5, CG100, KTT16, QS93 for Warfarin
- NG5, NG106, CH180 for Amiodarone
- NG5, CG185, CG192, QS95 for Lithium
To date, I have designed templates for controlled drugs, Hypnotics/Z-drugs, DMARDs (each orally administered drug has individualized template), NOACs, Warfarin, Lithium and Amiodarone.
These templates prompt the user to add compulsory details before the drug can be issued for the first time or for a repeat issue. This has led to better and safer prescribing and potential to identify group of patients who either have not been reviewed or have missed essential monitoring.
To avoid visual fatigue templates are short and to the point and a clinician can navigate away by one click if the required fields have been captured recently.
Audits of prescribing such drugs has shown better prescribing and more patient involvement in decision making.
- Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (NG5)
- Alcohol-use disorders: diagnosis and management of physical complications (CG100)
- Controlled drugs: safe use and management (NG46)
- Atrial fibrillation: management (CG180)
- Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia (TA77)
- Atrial fibrillation (QS93)
- Chronic heart failure in adults: diagnosis and management (NG106)
- Bipolar disorder: assessment and management (CG185)
- Antenatal and postnatal mental health: clinical management and service guidance (CG192)
Example
Aims and objectives
NICE recommends safe prescribing (NG5) and newer models of consultation place an emphasis on shared decision making, the templates provide the opportunity to implement this in practice.
The safe prescribing templates are intended to capture details regarding the high risk drugs including; indication, duration of intended use, dependency, patient's consent to informed decision making, therapeutic value (e.g. INR, lithium level), monitoring requirement (e.g. GFR, LFT, FBC, ECG etc) as well as diary entry for next review/monitoring. The following outcomes are intended from undertaking this work;
- Comply with monitoring requirement for high risk drugs
- Identify patients requiring early intervention
- De-prescribing if indicated
- Patient education.
Reasons for implementing your project
At the outset of this project we found several patients who have been prescribed certain medication (hypnotics, sedatives, opiates, CNS stimulants) dating back several years ago and continue to receive medication without a meaningful discussion about a known indication, assessment of dependency, and patient's consent to pros and cons of continuing with the medication. Such prescribing can unfortunately bring harm rather than intended therapeutic benefit. For instance patients who had been prescribed hypnotics/sedatives, only 16% of them had a discussion of their medication by name with offer of reduction or a withdrawal plan in 12 months before the audit date (Jan 2018).
Similarly prescribing of Cytotoxic /DMARD or other high-risk medication was found as an area where a visual reminder forthe prescriber regarding which monitoring should be in place will help towards safer prescribing.
How did you implement the project
I designed two different templates for the safe prescribing of Opiates and Hypnotics/Z-drugs. A decision to design these templates was made with all clinicians and their views were taken into account. The templates help a clinician to add the name of the drug, its indication, dependency status, intended duration of treatment, prompt for providing pros/cons information, declaration of patient's consent to treatment and a diary entry for the next review. The take up of templates was sporadic within first 6 months. Slow but steady improvement in follow up audits was shared along with trouble shooting Q&A sessions with the team at regular meetings.
As for Warfarin and Lithium, the individual templates request the user to add most recent INR/Serum Lithium level among other information and a diary entry.
Amiodarone, NOACs, DMARDs (each drug has individually tailored template) templates request the user to choose yes/no option for various monitoring requirement as per NICE/BNF. This also includes a diary entry for the next date of monitoring requirement.
The above templates are all on auto-run mode, however a clinician may choose to navigate away if the details have recently been captured.
I had equipped 7 practices with the above templates, with consent from the head of the organisation.
Key findings
We have 6 monthly rolling audits for controlled drugs, hypnotics, and NOACs at my GP practice. We also have a 3 monthly rolling audits for DMARDs, Lithium and Amiodarone.
Having implemented the above templates we have seen improvement in number of patients who have had a review in past 12 months. Following are some examples
|
Name of the Drug and parameter of audit |
Initial audit results |
Follow-up audit result |
|
NOACs: Patient has had LFT checked in past 12 months |
73% Oct 2018 |
93% Apr 2019 |
|
NOACs: Patient has had renal function checked in past 12 months |
75% Oct2018 |
95% Apr 2019 |
|
NOACs: Patient has had FBC in past 12 months |
70% Oct2018 |
90% Apr 2019 |
|
Mycophenolate Mofetil monitoring as per NICE pathway for DMARDs in previous 3 months |
0% May2018 |
100% Jun 2019 |
|
Lithium monitoring monitoring as per NICE pathway for Bipolar Disorder |
Li level 75%, GFR 50%, BMI 25%, TFT 100% Calcium level 0% in Oct 2018 |
Li level 75%, GFR 100%, BMI 100%, TFT100%, Calcium level 25% Sept 2019 |
|
Controlled drug where patient has a linked indication to the prescribed medication |
Tramadol 32% May 2018 |
Tramadol 85% Nov 2018 |
|
|
Oxycodone 8% May 2018 |
Oxycodone 100% Nov 2018 |
|
|
Morphine 31% May 2018 |
Morphine 93% Nov 2018 |
|
|
Buprenorphine 33% May 2018 |
Buprenorphine 93% Nov 2018 |
|
Warfarin prescribing where an indication was documented |
69% in Jan 2018 |
95% Jun 2019 100% Sep 2019 |
|
Warfarin prescribing where INR has been recorded in 12 weeks prior to issue |
89% in Jan 2018 |
95% Jun 2019 98% Sep 2019 |
|
Benzodiazepines prescribing where a clinical review of the drugs carried out by name in previous 12 months |
16% in Jan 2018 |
38% in Sept 2018 42% in Jul 2019 |
|
Benzodiazepines prescribing where an indication is known |
21% in Jan 2018 |
70% in Sep 2018 96.4% in Jul 2019
|
We have more drug name-based discussions documented in medical notes. We also have agreed on a policy to deal with chronic non-attendances for reviews.
This has helped raise awareness amongst patients about what drugs they are using and why regular reviews are important.
Key learning points
Even the most experienced clinicians can omit safety checks whilst signing lots of repeat prescriptions on daily basis. This can lead to patient safety incidents. Identifying patients who need additional support, education, deprescribing and optimizing all can lead to harm reduction.
From a prescriber's viewpoint it helps shift some responsibility of ongoing management towards patient/carer and documentation of clinical decision helps seamless transfer of care among clinicians. Reflecting on the practice I find the below points to be helpful;
- A template needs to be short and concise.
- It is helpful to trigger this as a prompt rather than auto-run mode for repeat issue.
- Meet with the users of such prescribing aid on regular and as required basis for reviews and trouble shooting.
- A regular audit cycle should be in place to determine the system efficacy.