1. Prescription Dr Soe Aung Myint Dr Soe Aung Myint

2. Take Thou

5. Learning Objectives What is prescription A plan for prescribing What is POS or Chart Order What is outpatient’s prescription form What are prescription errors Legal and socioeconomic factors

7. What is prescription Written order by a physician to pharmacist To supply drugs Definite dose form Definite composition,instruction and precautions for use

8. Introduction If u want to give a good prescription for patients you need to understand well pharmacokinetcs,pharmacodynamics and patophysiology And you have to avoid common prescription errors Good communication between PPP

10. INTRODUCTION Prescriber’s order to prepare or dispense a specific treatment for specific patient Usually medication In most case requires the writing of a prescription Patients with diagnosis Practitioner can select variety of therapeutic approaches MSPRPHECCN The options you need to choose

11. Rational Prescribing Make a specific diagnosis Patophysiology of diagnosis(mediators of inflammation)…NSAIDS Select a specific therapeutic objective Select a drug of choice Determine the appropriate dosing regime Plan for monitoring drug action Plan of patient education

12. Hospital setting of Prescriptions ♥ ♥ physician's order sheet (POS) or chart order. ♥ ♥ The patient's name written on the form. ♥ ♥ The orders consist name, strength of medication, ♥ ♥ dose, route and frequency of administration, ♥ ♥ the date, information, signature of the prescriber. ♥ ♥ The duration of therapy if not specified medications continued until the prescriber discontinues the order or ♥ ♥ until it is terminated as a matter of policy routine, e.g, a stop order policy.

14. Chart Order 11/15/08 11/15/08 10:30 a.m. 10:30 a.m. (1) Ampicillin 500mg IV q6h x 5 days (1) Ampicillin 500mg IV q6h x 5 days (2) Asprin 0.6 g per rectum q6h prn (temp over 101 F ) (2) Asprin 0.6 g per rectum q6h prn (temp over 101 F ) [signed]Janet B.Doe, MD [signed]Janet B.Doe, MD Elements of hospital chart order = (5,8- 11,15) of out patient prescription Elements of hospital chart order = (5,8- 11,15) of out patient prescription

15. Ingredients of Outpatient Prescription

17. Approximate conversions 1 grain (gr) = 0.065 grams (g), often rounded to 60 milligrams (mg) 15 gr = 1 g 1 ounce (oz) by volume = 30 milliliters (mL) 1 teaspoonful (tsp) = 5 mL 1 tablespoonful (tbsp) = 15 mL 1 quart (qt) = 1000 mL 1 minim = 1 drop (gtt) 20 drops = 1 mL 2.2 pounds (lb) = 1 kilogram (kg)

18. Approximate conversion quantity of solute in sufficient solvent 100ml The strength of solution is usually expressed as quantity of solute in sufficient solvent to make 100ml 20 gms of KCl dl 20% of KCl solution is 20 gms of KCl per dl [gm/dl] concentration volume Both concentration and volume should be explicitly written out Deciliter=dl

19. Salient features The drug name, purpose, duration of therapy should be written on each label so that drug may be identified easily in case of overdose. An instruction to "take as directed" may save the time it takes to write the orders out but often leads to noncompliance, patient confusion, and medication error. Directions for use must be clear and concise To avoid toxicity and to obtain the greatest benefits

20. Salient features 1. 1. Elements [12] to [14] of the prescription include refill information, waiver of the requirement for child proof containers, 2. 2. And additional labeling instructions (eg, warnings such as "may cause drowsiness," "do not drink alcohol"). 3. 3. Although directions for use are no longer written in Latin, many Latin apothecary abbreviations (and some others included below) are still in use.

22. Abbreviations Used in Prescriptions and Chart Orders. Abbreviations Used in Prescriptions and Chart Orders. ABBREVIATION EXPLANATION Before ac before meals agit shake, stir Aq water Aq dest distilled water Bid twice a day Cap capsule D5W, D5W dextrose 5% in water dil dissolve, dilute disp, dis dispense elix elixir ext extract g gram gr grain gtt drops h hour hs at bedtime IA intra-arterial IM intramuscular IV intravenous IVPB IV piggyback kg kilogram mEq, meq milliequivalent mg milligram mcg, µg (do not use) microgram (always write out "microgram") no. number non rep do not repeat

23. More abbreviations OTC → → over-the-counter OU → → both eyes pc → → after meals PO → → by mouth PR → → per rectum prn → → when needed q → → every qam, om → → every morning qd → → every day qh, q1h → → every hour q2h, q3h, etc → → every 2 hours, every 3 hours, etc qhs → → every night at bedtime qid → → four times a day qod → → every other day qs → → sufficient quantity

24. More abbreviations rept, repet → → may be repeated Rx → → take thou SC, SQ → → subcutaneous Sig, S → → label Sos → → if needed ss → → one-half stat → → at once sup,supp → → suppository susp → → suspension tab → → tablet tbsp, T → → do not use) tablespoon (always write out "15 mL") tid → → three times a day tr, tinct → → tincture tsp → → (do not use) teaspoon (always write out "5 mL") U → → (do not use) units (always write out "units") vag → → vaginal

25. Abbreviations not recommended a.u., a.s., a.d. - Latin for both, left and right ears; the "a" can be misread to be an "o" and interpreted to mean both, right or left eyes bt - intended to mean "bedtime", but can be misread as "bid" or twice daily. d/c - can mean "discontinue" or "discharge" h.s. - can mean half strength or "hour of sleep “

26. Abbreviations not recommended IJ - intended to mean "injection", but can be misread as "IV" IN - intended to mean "intranasal", but can be misread as "IM" or "IV" IU - intended to mean "international unit", but can be misread as "IV" or "10" o.d., o.s., o.u. - the "o" can be misread as "a". o.d. - can mean "once daily" or "right eye". OJ - intended to mean "orange juice" but can be misread as "OD" or "OS" Abbreviations not recommended IJ - intended to mean "injection", but can be misread as "IV" IN - intended to mean "intranasal", but can be misread as "IM" or "IV" IU - intended to mean "international unit", but can be misread as "IV" or "10" o.d., o.s., o.u. - the "o" can be misread as "a". o.d. - can mean "once daily" or "right eye". OJ - intended to mean "orange juice" but can be misread as "OD" or "OS"

27. Not recommended Abbreviations q4PM - intended to mean "at 4 PM", but can be misread as every 4 hours q.d., q1d - intended to mean "every day" but can be misread as "q.i.d." or 4 times a day q.o.d. - meant "every other day" but the "o" can be interpreted as "." or "i" resulting in double or eight times the frequency SC - meant "subcutaneous" but mistaken for "SL" for "sublingual" SQ - meant "subcutaneous" but mistaken for "5Q" or 5 every dose

28. Not recommended abbreviation 1. 1. 'ss - intended to mean "sliding scale" or "1/2", but can be mistaken as "55" 2. 2. 'SSI, SSRI - intended to mean "sliding scale insulin" or "sliding scale regular insulin", but can be mistaken as "strong solution of iodine" or "selective serotonin reuptake inhibitor 3. 3. T.I.W - meant 3 times a week but mistaken for twice a week 4. 4. U - meant "units" but mistaken for "0", "4" (so "4U" can become "40" and the "U" is assumed), or misread as "cc" when poorly written; conversely cc can be mistaken for "U" 5. 5. μg - meant "microgram" but mistaken for "mg"; this 1000- fold error can cause potentially fatal misunderstandings

30. Common prescribing errors   Wrong dose   Inappropriate Units   Wrong drug (e.g. drugs that sound alike)   Poor/illegible prescriptions(.1 is easily misread as 1)   Failure to take account of drug interactions   Omission of information   Wrong route/multiple routes (IV/SC?PO)   Calculation errors (important in Paediatrics)   Poor cross referencing   Infusions with not enough details of diluent, rate etc. Poor cross-referencing between charts   Once weekly drugs   Multiple dose changes

32. Compliance and Noncompliance The extent to which patients follow treatment instructions Patients fails to obtain medication,leave the hospital without discharge medications Fails to take medication as prescribed(inadequate communication)ppp Prematurely discontinues medication(symptomatic improvement) Takes anappropriately(share)

33. Look Alike Drugs

35. Scrutinize

36. Lidocaine Administering the wrong drug could be fatal “NHS standard”: Water Sodium chloride Lidocaine (lignocaine)

37. Confusers Drugs that sound alike Clotrimazole/ Co-trimoxazole Carbamazapine/ carbimazole Risedronate/ Methotrexate Drugs that look similar in writing ISMN / ISTIN

38. Prevention of Medication Errors The Five R’s The Five R’s Right Patient Right Patient Right Drug Right Drug Right Dose Right Dose Right Route Right Route Right Time Right Time

39. PME Identifying the patient by asking name Ask patient why he or she take this medications,food and drug allergy,expired date,check label 3-times Dose on order must be recommended guideline Plasma half life of drug,before meal and after meal Oral,sublingual,inhalation,subcutaneous,intr avenous,like that

40. Principles of Good Prescribing   Use addressograph for patient details   Complete allergy box and alert label   Use generic drug names(difference in cost between trade name product and )   State drug, dose, strength, route and frequency   Avoid abbreviations   Avoid multiple route prescribing (i.e. im/sc/po)   State dose as grams, mg,   Make administration of once weekly drugs clear   To amend a prescribed drug – draw a line through it, date and initial, then rewrite as new prescription.

42. Legal Factors(USA) Recognizes two class of drugs (1) over-the-counter(OTC) drugs (2)those that require a prescription from a licensed prescriber Pharmacist are authorized to dispense prescriptions persuant to prescriber’s order Nurses…..

43. Prescription drugs are controlled by US Food and Drug Administration Prescription is actually three things Physician’s order in the patient’s chart Written order to which pharmacist refers Patient’s medication container with a label affixed Prescriber must pass exam,pay fees,continue education(board of medical examiners) for license

44. Controlled Drugs Prescriptions  Handwritten  NAME, FORM & STRENGTH of drug and dose Morphine sulphate SR tablets 10mg 20mgbd  Methadone liquid 1mg/ml 10ml od  TOTAL QUANTITY in WORDS and FIGURES  50 (Fifty) tablets  20 (twenty) ml  YOUR Signature and DATE (include bleep no.)

45. Hospital Prescribing Includes : Evaluation of patient’s current medication Selecting medication for treatment - indication, formulary, licence agreements, efficacy Stating considerations - antibiotics: duration of treatment - warfarin: discharge dose & next INR date Discharge medication = not just a rehash of the drug chart

46. Parenteral Administration In some hospitals it is part of the usual drug chart

47. Discharge Prescriptions   Record all drugs the patient should take even if no supplies are required on discharge. .  Record drugs that have been stopped or significant changes.

48. Warfarin Chart

49. Insulin Chart

50. Write legibly – spell correctly Sign properly with your name below

51. Resembles a Letter OPD Prescriptions Superscription – Like a letter head Patients particulars Patients address Rx Inscription - All about the drug with the instructions to the patient Transcription - Instructions to the pharmacist Subscription - Signature Doctors name & Registration number

54. Socioeconomic factors Generic prescribing….difference in cost between trade name product and generic product s varies from <twofold to more than 100-fold. If prescriber wants a particular brand of drug products dispensed,handwritten instructions to “ dispense as written” Many practitioners avoid generic prescribing,thereby by increasing medical cost