Safe Prescribing of High Risk Drugs

This month we are very proud when one of our own had her work published by NICE. Aneela runs a range of courses at Belmatt and regularly provides case studies for our Advanced Practitioners on our WhatsApp group.

Please see her article published in NICE guidelines below: https://www.nice.org.uk/sharedlearning/safe-prescribing-of-high-risk-drugs

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 for the 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

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.

About the Author: Aneela Tehseen, Clinical Pharmacist

I am a clinical pharmacist with a special interest in promoting safer prescribing.

I currently provide educational support to many organisations in the area of prescribing optimisation.

I also am lead for medicine management and pathway development for a group of GP practices.

Over the years I have successfully designed and implemented several innovative projects of safer and improved prescribing focussed on harm reduction.

Nations institute for Health and Care Excellence (NICE) published my achievements on safer prescribing of high risk drug in Oct 2019 in shared learning domain. This can be found here https://www.nice.org.uk/sharedlearning/safe-prescribing-of-high-risk-drugs

Then in Oct 2020 a resource that I developed to improve prescribing of Schedule 2,3 controlled drugs as well as Hypnotics/ sedatives was approved and published by NICE. It can be found here https://www.nice.org.uk/guidance/ng46/resources/endorsed-resource-safer-prescribing-of-controlled-drugs-schedule-23-hypnotics-and-sedatives-in-primary-care-8895631213

Recently we achieved another significant success in reducing total Steroids and antimicrobial rescue pack prescribing in COPD patients. This was a project rolled out in a practice where a very high demand/ supply of rescue packs was flagged up as a result of my audits. We have achieved 59% reduction in antimicrobial prescribing and 45% reduction in oral steroids prescribing over 6 months without increase in hospital admissions. This is a phenomenal success.

Now the organisation is seeking to replicate in other practices where the analytical audits have shown an inappropriate prescribing.

Obviously all above is a result of teamwork and I am very proud of all my team members for their support and perseverance through the challenges of change.

We have several other projects in the pipeline such as reducing Codeine prescribing, a forgotten area (as it’s not schedule 2,3 CD , it often slips through the net).