Pharmaceutical Services at DGRI Mon - Fri 8.30 - 5.00 Sat - Sun 9.00 – 17.00 (Last prescriptions received in pharmacy by 4pm) On-call via switchboard for advice or emergency supplies only

Pharmaceutical Services at DGRI Clinical Aseptic Dispensary Medical Information

Clinical Service The pharmacist is responsible for ensuring prescribing is safe, effective, and economical Clinical pharmacists aim to review new patient admissions in ward 7/8/ICU daily, but annual leave and public holiday cover is not provided so do not assume that we have seen everyone! See notice in doctors room for pharmacist ward cover: medical wards call ext 31318 surgical wards call ext 32990

Clinical Service (contd) Ward cover varies therefore contact pharmacy if there is a patient you would like us to review Happy to answer your questions

Aseptic/Nutrition Service Sterile production of all cytotoxics Nutrition team manage ordering of all TPN (total parenteral nutrition) Orders must be in pharmacy by 11am Ensure you request daily bloods indicating ‘TPN bloods’ on biochemistry form Caution with concurrent fluids-TPN already provides maintenance, extra only required if replacement fluids indicated

Dispensary Service Every prescription is clinically checked by a pharmacist before it can be dispensed, any errors or queries will hold up the dispensing process (can take 20 minutes or longer per patient) We need at least 1 hour to dispense a prescription after clinical check 4 hours is required for blister pack prescriptions to be dispensed safely Check the prioritisation of discharge prescriptions with your ward team (e.g. morning ambulances or compliance issues)

Dispensary Service (part 2) Patients get frustrated when they are told at 9am to go home but their prescription is not typed until 3pm Manage patient expectation - When you tell patients they can go home make sure they have a realistic understanding of how long it will take to get their medicines ready including you getting time to write the discharge No pharmacy staff capacity for prescriptions received after 4pm to be completed the same day

Medicines Information Service Deal with any enquiry regarding medicine For inpatients always contact your ward clinical pharmacist with any medicine enquiry We answer enquiries from within the hospital as well as from GPs, district nurses, patients, community pharmacists etc. The medicines information phone is not permanently staffed - answering machine checked throughout the day

Prescribing HEPMA (Hospital Electronic Prescribing and Medicines Administration System) is being rolled out across DGRI in 2015/2016 This requires all inpatient medicines to be prescribed and their administration recorded via an electronic system. HEPMA also provides discharge medication information to the Immediate Discharge Letter.

Prescribing (contd) Live throughout DGRI excluding ICU / A&E / Paediatrics / Obstetrics Psychiatry and Paediatrics planned Autumn 16 Initial training via LearnPro (or at induction) No training = No password ASK if you need help! HEPMA team on x32410.

Prescribing (contd) The majority of prescribing should be generic Some drugs must always be prescribed by brand e.g. theophylline, lithium, diltiazem, all anti-epileptics see formulary for list Preparations containing more than one drug may be prescribed by brand e.g. Rifinah tablets Indicate if a modified release preparation is required-omitting this can be clinically significant eg. Carbamazepine MR

Prescribing (contd) Supplementary medicine charts for variable dose medicines will still require a handwritten chart e.g. warfarin, insulin, heparin, gentamicin, vancomycin A medication chart is essentially an item of written communication, but it also has legal importance You must write clearly so that the nurses can carry out your instructions without asking for further clarification Please write in block capitals, sign, and date each drug. Always include your phone number

Prescribing Cost Effectively Prescribe according to formulary on Hippo and in doctors handbook Any requests for non-formulary products must include reason for request (HEPMA will enforce) & will be authorised by pharmacy New medicine process Assessment – clinical benefit, cost, safety, impact in primary care If non Scottish Medicines Consortium approved or unlicensed – needs to go to Medical Director/ Exceptional prescribing committee

Prescribing in Out-patients Use blue HBP5 prescription pad Advise patients that medicine will be dispensed by a community pharmacy of their choice. We only dispense for inpatients or if a hospital only medicine is required Use the formulary Generic name (unless clinically appropriate to use brand) PRINT contact number and clinic Prescribe quantity – max 1 month

Patients Own Drugs All patients encouraged to bring in PODs, these are assessed & placed in their wall locker for use with medicine reconciliation & on medicine rounds Any medicines not brought into hospital or additional drugs will also be placed in the locker These medicines will either be transferred with the patient to their next ward or be sent to pharmacy with the discharge prescription

Medicines Reconciliation Med Rec =obtaining the most accurate list of a patient’s current therapy Electronic med rec is being rolled out across the organisation and is more efficient(see a pharmacist for more info) This will become a significant part of your role as a hospital doctor, a complex med rec can take up to 20 minutes to complete Med Rec should be carried out on admission, checked at each ward transfer & discharge.

Medicines Reconciliation Use all available resources (minimum of 2) -ask patient/carers what they are actually taking. Review medications in line with current clinical condition and document changes Must be performed for EVERY patient Accuracy is audited as part of the Scottish Patient Safety Programme

Medicines Reconciliation You must complete the Module on LearnPro Remember 50% of handwritten GP letters are inaccurate Over the counter & hospital only medicines may not be listed in GP records! You must speak to your patient/carer If in doubt contact your clinical pharmacist

Insulin High risk drug – common source of errors Prescribe dose “as charted” on Medication chart / HEPMA and refer to insulin chart Select the correct device - Flexpen, penfill, vial Variable rate insulin charts contain full guidance Always write ‘units’ in full, do not abbreviate Include a note of the current dose being used in units on discharge prescription

Controlled Drugs Fentanyl Patch 50 micrograms/hour topical One Legal requirements for discharge prescription as per layout on IDL. Info in handbook and BNF (both online!)-usually prescribe 7 days worth on discharge Common errors= the strength, form of preparation and total quantity to supply missing! Drug/ Form of preparation Route of Admission Dose Frequency Days Recommended Fentanyl Patch 50 micrograms/hour topical One every 72 hours 2 (Two) patches Midazolam Injection 10mg/2ml Sub- cutaneous 5mg over 24 hours sc 7 amps (seven) Note if prescribing more than one strength of a medicine-prescribe each strength separately as example below with morphgesic dose of 50mg BD Morphgesic tablets 10mg oral 20mg BD 28 tabs (twenty eight) Morphgesic tablets 30mg 30mg 14 tabs (fourteen)

Steroids Always check indication Check current dose with patient as GP records only state ‘as directed’ with variable dose regimes If oral route unavailable switch to IV hydrocortisone (see handbook for details) State course length on discharge- if long term then please state this-risk of addisonian crisis if stopped Consider tapering down regime if had >3 weeks treatment

Inhalers/Nebules High cost medicines! Device type-accuhaler, easibreathe, diskhaler, turbohaler, MDI, easyhaler Strength-not the number of doses in the device! Beclometasone-prescribe as brand QVAR or Clenil Modulite Does the patient have a home nebuliser? Do not give ipratropium nebules and tiotropium inhaler together

Antibiotics Antibiotic guidelines are on HIPPO Follow them – if deviate document why. They’re all on HEPMA starting ABX- You will be questioned if you prescribe a restricted antibiotic to check it has been recommended by infectious disease or microbiology consultant Document stop date on HEPMA for all oral antibiotics and after 72 hours of IV antibiotics document a review plan using a note in HEPMA. IV antibiotics should be reviewed daily after 72 hours Document indication for antibiotic using note in HEPMA it helps ensure efficient and effective communication Gentamicin therapy should not continue longer than 3 days without discussion with consultant microbiologist to establish risk/benefit and other treatment options If a patient receives gentamicin for longer than 7 days they should be referred to audiology

Warfarin Document dose on medication chart / HEPMA “as charted” and refer to warfarin chart Document INR target and indication on warfarin chart Check for interactions/liver disease. Watch INR if starting antibiotics! All new start patient’s require counselling-refer to pharmacy You must organise follow up INR appointment at discharge

Benzodiazepines Clozapine Review need at discharge Advised for short term use only Clozapine Always alert pharmacy team -contact on call pharmacist if you cannot find the dose Missed doses will be treated as a critical incident

Analgesics/Antiemetics See Acute Pain Team protocol Caution regular & PRN analgesic duplication i.e. paracetamol and co- codamol Caution: reduce IV and oral paracetamol dose to 15mg/kg QD if less than 50kg Only prescribe one opiate at a time i.e. if regular morphine stop codeine Tramadol is second line as a step 2 analgesic (also needs to be prescribed as a controlled drug) Antiemetics-think pharmacology, check for contraindications

Allergies can be fatal! Errors have occurred where patients have been prescribed and given penicillins despite having a documented penicillin allergy. Make sure you are not the unlucky one who causes a patient to suffer anaphylaxis. Please check allergy status before prescribing any medicine. HEPMA will warn you – read the warning!

Allergy Status Always check allergy status in notes, GP letter, with patient/ relative. HEPMA may have allergies from previous admissions– check still accurate. Must be recorded in the notes on the medicine chart on the discharge prescription What is the reaction-true allergy? If a new allergy is discovered, record it.

Emergency Care Summary Remember ECS has been found to be only 80% accurate Watch issued dates-patient may have stopped a medicine Medicines prescribed at hospital clinics won’t always be recorded on ECS as this has only recently started happening

Discharge Prescriptions Should be done ASAP-traffic light system on ward boards, liaise with ward charge nurse Use HEPMA and the electronic immediate discharge programme Include ALL the drugs the patient is on Controlled Drugs- advice in handbook/Hippo/BNF or ask us if still in doubt! If within pharmacy hours – pharmacist verifies discharge prescription before e-mailing to GP and printing off patient & casenote copies.

Discharge prescription checklist This may take at least 20 minutes – plan your time Perform medicines reconciliation using medicine chart & medicines reconciliation form on admission Speak to patient/pharmacy team if any discrepancies noticed (you will pick up many errors at this point) Where are they being discharged to? Transfers to peripheral hospitals must be stated Pharmacy copy must be signed including phone no. Have you given it to nursing staff? Nursing staff alert pharmacy team If after 4pm contact ward pharmacist directly as there may not be capacity for late/unplanned prescriptions

And Finally………... we cannot dispense prescriptions for members of staff - if you need a prescription, get a GP! we are here to help you with anything to do with drugs, prescribing, administration, availability, compatibility, etc. Please ask for help as we do not provide a clinical service to all wards.