B N F, Pharmacology And Prescribing In The N H S

Grzegorz Chodkowski (MD)Grzegorz Chodkowski (MD)

Riga, Radisson SAS

2009

BNF, Pharmacology BNF, Pharmacology andand

Prescribing in the NHSPrescribing in the NHS

BNF

BNF British National Formulary

Published twice a year ( March/October )by British Medical Association& Royal Pharmaceutical Society of Great Britain

www.bnf.org

FREE ! on-line access by users from Latvia

The HistoryThe History

BNF Today

Provides:• Guidance on prescribing• Relevant information on prescription drugs in UK• Appendices on drug interactions and

prescribing in pregnancy, whilstbreast feeding and for those with liveror kidney disease

Appendix

The BNF is…• The best available• Up to date – published every 6 months• Succinct • Accurate• Also available as BNF.org

Who gets the BNF in the UK?About 250,000 copies are published which go to all:• Doctors• Medical students• Pharmacists• Pharmacy students• Hospital wards and clinics

• Plus dentists and nurse prescribers

Who gets the BNF overseas?

• Licensed translations for Spain, Turkey and Italy

• Unlicensed use in many countries• Pharmaid sends 6-12 month old BNFs to

Commonwealth countries • BNF.org available across the world

The BNF for Children – BNFC

• Children are a challenge • Come in different sizes• Grow and develop and • Clinical trials difficult• Data very limited• Many drugs not licensed for use in children

MMedicines and edicines and HHealthcare ealthcare products products RRegulatory egulatory AAgencygency

The Yellow CardReporting of suspected Adverse Drug Reactions by health

professionals and patients

Routine publication of aggregated yellow card data on the MHRA web site

PublicationsThe MHRA currently publishes some 80 types of output, which are now being reviewed as part of the Agency’s communication strategy

Pharmacology

tableteffervescent / soluable / dispersible/coated tablet

capsule

granule

suppository

suspensionoral suspension

syrup

injection

ointment

gelvaginal gel

solution

foam

pessary

aerosol

dry powder for inhalation

patch

spraynasal spray

aerosol

dropseye /oral drops

Drug dosageo.mo.n

omni mane / every morningomni nocte / every night

od once daily

b.i.d lat. bis in die / two times daily

t.d.s t.i.d

lat. ter in diem summendumlat. ter in die three times daily

qdq.i.dq.d.s

lat. quarter in dielat. quarter in dielat.quater in die summendusfour times daily

p.r.n lat. pro re nata / as and when required

stat lat. statim / at once

noctè at night

qh lat. quaque hora / every hour

q2hlat. quaque seconda hora / every 2-nd

hour

Latvian Abbreviation Englishi.m

i.p

intra-muscular

intra-peritoneal

i.v intravenous

s.c subcutaneus

top. topical

i.a intra-articular

p.o by mouth / orally

p.r per rectum

top. topical

Routes of Administration

Latvian Abbreviation EnglishNG

Neb

Naso-gastric tube

nebulisation

Inh inhalation

NJ Naso-jejunal tube

PEG Percutaneous Endoscopic Gastrostomy

PEJ Percutaneous Endoscopic Jejunostomy

SL sublingual

Routes of Administration

Basic drug groupsanalgesics (pain killers)antiemeticsantidiarrhoealsanti-inflammatoriesantihistaminesantihypertensivesanti-anxiety drugsantibioticsantacidsproton pump inhibitorsanti-arrhythmicsanticoagulantsanticonvulsantslaxativessex hormonessleeping drugs

antipyreticsantispasmodicsantiviralsbeta-blockersbronchodilatorscold cure remediescorticosteroidscough suppresantscytotoxicsdiureticsdecongestantshormoneshypoglycaemicsImmunosuppresantsvasodilatorsvitamins

Controlled Drugs

Controlled Drugs

Pain managment Paracetamol 500mg 1-2 tabl. every 4-6 h max. 4h daily i.v >>>(Parfalgan) 1g for15min. every 4-6h, max. 4g daily

Paracetamol + codeine every 4-6h Co-Codamol – 500/8 mg Co-Dydramol – 500/10 mg Solpadol – 500/30 mg

Mild narcotics (opiates) codeine 30-60 mg p.o/p.r >>>constipation!!!

NSAIDs (Non-steroidal anti-inflammatory drugs)

Diclofenac (Voltrol ®) 75mg-150mg p.o tds/qds 75mg o.d i.m max. total daily dose 150mg Ketoprofen (Orudis ® , Oruvail ® ) 50mg tds p.o

Anti-emeticsOndansetron (Zofran ® ) 0.15mg / kg i.v for 15min usually 4mg, also deeply i.m

Cyclizine 50mg p.o / i..v / i.m TDS

Metoclopramide (Maxolon ® ) 10mg i.v for 1-2 min TDS also p.o / i.m

Post opiates/anaesthesia Phenothiazines best:Prochlorperazine: nausea > 20mg , po 2h 10mg prophylactics: 5-10mg 2-3 times / daily 25mg supp. initially, then after 6h changed for 5-10 mg p.o or deeply i.m 12.5mg, then after 6h changed for 5-10 mg p.o Chlorpromazine: 10-25mg every 4-6h p.o 25 mg i.m, followed by 25-50mg every 3-4h 100mg supp. every 6-8h

AntibioticsMost common: PENICILINES

Amoxicilin AugmentinAMINOGLICOSIDES (When allergic to penicylines)

ErythromycinCHINOLONES

FlucloxacilinCiprofloxacin

CEPHALOSPORINESCefuroxime (Zinacef®) 750mg i.v TDS

in surgical prophylaxis: 1.5g i.v pre-op, 750mg intra-op, 750mg post-op

Fluid balance assesment- crackles over lungs- skin tone- JVP - capillary fill- HR / BP- urinary output- HgB

Prescribing

PoM – Prescribing Only Medicines

„…it is important to discuss treatment options carefully with the patient to ensure that the patient is content to take the medicine as prescribed…”

Prescribing Standard- prescription should be in black ink or computer

generated- legible writting- signed in ink by presciber- drug names should not be abbreviated- prescription should include: - full name and address of the patient - age and DOB (optional) but necessary in children under 12

The standard- ‘micrograms’ and ‘nanograms’ and ‘units’

should not be abbreviated- know & document allergies- weight- dose should be written in clear numbers, without unnecessary decimal points e.g 8mg not 8.0mg

1g not 1.0g 500mg not 0.5g

Amoxicilin oral suspension125mg/5mL sugar free125mg three times dailySupply: 100ml

(No more items on this prescription)

Sample prescribing

Antacids- Aluminium hydroxide 1-2 tablets chewed- Magnesium Carbonate 10mls t.d.s- Gaviscon 10-20 mls- H2 receptor antagonists Ranitidine 150mg b.i.d

- Proton Pump Inhibitors Omeprazole 20mg o.d

Sleeping medications

Temazepam 10 - 20 mg noctè

Lorazepam 0.5 - 1mg noctè

Zopiclone 3.75 - 7.5 mg noctè

Nytol 25mg - 50mg noctè

Diazepam 2mg – 5mg noctè

Intravenous managment• Purpose: - fluid balance managment - replacement of lost fluid

- Glucose / Dextrose D5W – 5% Dextrose water

- Normal Saline / 0.9 % Saline- Hartmann’s Solution- Ringers Solution

Pre-op routine

- sedation (benzodiazepines - Diazepam)

>reversal agent: Flumazenil ( 200μg over 15s followed by 100μg at 1min. Intervals)

- stopping Warfarin

Proton Pump Inhibitors

Omeprazole (Losec ®) 20mg od

Pantoprazole

Lansoprazole (Zoton ®) 30mg od

Prescribing

Patients Vary

• Know the medicine well enough to administer safely • Check and be certain of patient identity • Know the care plan • Administer in the context of patient condition • Check for allergy and

the expiry date before administering • Know the following so you correct and understand

prescription instructions:

Key PointsKey Points

• Medication prescribing is: – Appropriate – Safe – Legible – Accurate – Clear – Indelible

• The patient must be identifiable

– patient's name – address – date of birth – hospital number – age if under 12 (legal requirement) – weight if under 12 (legal requirement)

Prescribing Core KnowledgePrescribing Core Knowledge(for all clinical staff)(for all clinical staff)

• The Allergy box must not be left empty • Use approved names (rINN) in black ink and BLOCK CAPITALS • Metric doses • Write micrograms and units in full • Indicate the route and times of administration • Administration times should be agreed with the nursing team and the 24-

hour clock used. Specify precise times if important. • Do not alter existing prescriptions. Rewrite if a change is made. • Only one chart should be active • Discontinue a treatment by crossing through it and cancelling subsequent

recording panels. Add your initials and the date. • Antibiotics must be prescribed for a stated time period. • Place X in administration box to indicate drug not to be given at specific

time & day • If a drug is to be administered by a pre-prepared protocol or patient

specific direction this must be explicitly referred to on the chart

Prescription Chart StandardsPrescription Chart Standards

Safe prescribing depends upon you putting yourself in the mind of everyone who might read and act on your script, patient, nurse, pharmacist and fellow prescriber.        

Dangerous errors tend to be:• Wrong medication in context• Wrong dose (too much)• Mistakes, are more likely when tired or distracted or interrupted. Every-one makes

mistakes and every one will make the occassional bad mistake • Team work and taking responsibility for checking others and then acting appropriately is

the most effective way of reducing patient harm. • All should accept the correction of potential mistakes in good grace  • Many safety issues are due to culture and can be corrected by system change • Insulin is the most common cause of administration error • Anticoagulants are the most common cause of life threatening prescribing error.• All clinical staff should know the risks with prescribing so they can be detected.

Medicines SafetyMedicines Safety

• Methotrexate given daily instead of weekly • Writing ug for microgram which might be read as mg and patient given 1000 times

too much. • Allergy box on drug chart left empty • Three fatal episodes where a prescriber prescribes a penicillin to someone

documented to be allergic penicillin and the penicillin is given despite the allergy being stated on the wrist band(s) and drug chart

• A study comparing administration error in UK, Germany & France found – Product not labelled/incorrectly labelled in 43%, 99% and 20% of doses respectively – Wrong diluent used in 1%, 49% and 18% – Wrong administration selected for 49%, 21% and 5% of doses observed – At least one deviation from aseptic technique was observed among 100%, 58% and 19% – In the UK, no cleaning of preparation area or hand washing was observed for any of the

prepared doses – Only 1% of cases swabbing the vial top – In the UK, the most frequent medication errors were related to an incorrect

administration rate (48%).  

Examples:Examples:

No Stamp

Package inserts• Dosage and directions for use• Side-effects and special precautions• Known symptoms of over-dosage and particulars of

its treatment• Identification• Presentation• Storage instructions• Registration number or reference number• Name and address of the holder of the certificate of

registration• Date of publication

Thank You!Thank You!

Any Questions?Any Questions?