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

2. Pharmaceutical Services at DGRI
Clinical
Aseptic
Dispensary
Medical Information

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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.

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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)

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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!

28. 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.

29. 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

30. 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 ing to GP and printing off patient & casenote copies.

31. 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

32. 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.