A guide to good prescribing practice for prescribing ...€¦ · NHS Education for Scotland | A Guide to Good Prescribing Practice for Prescribing Pharmacists in Scotland The first

NHSEducationforScotland|AGuidetoGoodPrescribingPracticeforPrescribingPharmacistsinScotland

The first pharmacist prescribing course in the United Kingdom for supplementary prescribing (SP) was held in 2003 at the Robert Gordon University in Aberdeen with pharmacists able to practice as SP from 2004 onwards. Independent prescribing (IP) courses together with legislative changes to allow practice as IP’s by pharmacists were introduced in NHS Scotland in 2007/08. Since 2003 around 900 pharmacists within Scotland have undertaken a prescribing course with many utilising their qualification in their clinical practice in collaboration with the multi-disciplinary team.

NHSEducationforScotland(NES)havebeenattheforefrontofsupportingpharmacistsinScotlandundertakingtheadditionaltrainingtobecomepharmacistprescribers,toultimatelyimprovepatientcare.AworkingsubgroupforPharmacistPrescribingoftheNESPharmacyProfessionalAdvisoryGroupinitiatedthisdocument,attherequestofprescribers,astherewerenocurrentguidancedocumentstosupportpharmacistprescribersintheirpracticenorarethereanystandardsforpracticecurrentlyforpharmacistprescriberspublishedbytheregulator,theGeneralPharmaceuticalCouncil(GPhC).

Thisdocument,A Guide to Good Prescribing Practice for Prescribing Pharmacists in NHSScotland,hasbeendevelopedbyNHSEducationforScotlandinconjunctionwitharangeofexperiencedpharmacistprescribersfromacrossthesectorsofpharmacypracticeandageographicalspreadacrosstheHealthBoards.

NHSEducationforScotland(NES)wouldparticularlyliketoacknowledgetheGeneralMedicalCouncil(GMC)andtheNursingandMidwiferyCouncil(NMC),asthemajorityoftheguidanceisbasedonappropriateguidancefromtheirrelevantguidancedocuments–GMCGood Practice in Prescribing Medicines (2008)andtheNMCStandards of Proficiency for nurse and midwife prescribers (2006)

NESwouldparticularlyliketothankthefollowingpharmacistprescriberswhocontributedtothedevelopmentofthisguidance:

Fiona Reid,NES(Lead)

Fiona Stewart,NHSForthValley

Carole Callaghan,NHSLothian

Deborah Paton,NHSFife

Valerie Sillito,NHSGrampian

Fiona MacLean,NHSGreaterGlasgow&Clyde

Ruth Forrest,NHSGreaterGlasgow&Clyde

Steve McGlynn,NHSGreaterGlasgow&Clyde


YoumayonlypracticeasapharmacistprescriberwhenyouhavesuccessfullycompletedaGPhCapproveduniversitycourseandhaveregisteredwiththeGPhC.Pharmacistsmayprescribeassupplementaryprescribers,independentprescribersoracombinationofboth.

Supplementary prescribing is defined as:Avoluntaryprescribingpartnershipbetweenasupplementaryprescriber,anindependentmedicalprescriber(whoisadoctororadentist)andthepatient.Thesupplementaryprescriberworkswithinanagreedpatient-specificclinicalmanagementplan.

Allpharmacistscanprescribeunlicensedmedicines,controlleddrugsand‘off-label’medicinesassupplementaryprescribersprovidedtheyareincludedintheclinicalmanagementplan.

Independent prescribing is defined as:Apractitionerwhoisresponsibleandaccountablefortheassessmentofpatientswithdiagnosedorundiagnosedconditionsandfordecisionsabouttheclinicalmanagementrequired,includingprescribing.

Pharmacistindependentprescribersemployedashospitalorprimarycarepharmacistscanprescribeanymedicinewithintheircompetencyandforwhichtheyarepreparedtoacceptlegalresponsibility,including‘off-label’medicines,unlicensedmedicinesandcontrolleddrugs.

Communitypharmacistindependentprescriberscanprescribeanymedicinewithintheircompetencyandforwhichtheyarepreparedtoacceptlegalresponsibility,including‘off-label’medicinesandunlicensedmedicinesbutcurrently excluding controlled drugs.CommunitypharmacistswillbeunabletoprescribecontrolleddrugsuntiltheHealthBoardPharmacistIndependentPrescribingService(Scotland)Directions2007havebeenamended.

PharmacistprescribersshouldensurethattheyhaveProfessionalIndemnityInsuranceinplacewhichcoverstheirprescribingactivities.


2.1 Youareprofessionallyaccountable foryourprescribingdecisions, includingactionsandomissions,andcannotdelegatethisaccountabilitytoanyotherperson.

2.2 Youmustonlyeverprescribewithinyourlevelofexperienceandcompetence.

2.3 Ifyoumove toanotherareaofpractice,youmust consider the requirementsofyournew roleandonlyeverprescribewithinyourlevelofexperienceandcompetence.

2.4 Youmustrefertoanappropriateprescriberifyoudonotfullyunderstandtheimplicationsofyourprescribingeventhough youmaybeabletotakeathoroughandappropriatehistorywhichleadstoadiagnosis.

2.5 Pharmacists’arelegallyentitledtoprescribefromawiderangeofmedicineshoweveryoushouldonlyprescribemedicinesforpatientswithinyourpersonalexpertiseandcompetence.


Agreement

3.1 Pharmacist prescribersmust ensure that individual patient agreement has been obtained prior to assessmentandpatientmanagement(whichmayincludeprescribing).In instanceswherepatients’areunabletoagreetomanagementbythepharmacist,processesmustbeinplacetoensurethisissoughtfromrelatives/carers.

http://scotland.gov.uk/Resource/Doc/216923/0058136.pdf

Assessment and Diagnosis

3.2 Inordertoprescribeforapatientyoumustsatisfyyourselfthatyouhaveundertakenafullassessmentofthepatient,includingtakingathoroughmedicalhistoryand,wherepossible,accessingafullclinicalrecord.

3.3 Youmustensureariskassessmenthasbeenundertakeninrespectofthepatient’scurrentmedicationandanypotential forconfusionwithothermedicines i.e.anypreviousadverse reactions tomedicines;currentmedicalconditionsandconcurrentorrecentuseofmedicines,includingnon-prescriptionmedicines.

3.4 Youmustmakeitcleartothepatientthatyourprescribingactivitycannotbeundertakeninisolation.Youmustinform,whererelevant,anyoneelsewhomaybeinapositiontoprescribeforthatpatientofyouractionsinordertoavoidprescribingerrorsbydocumentingyouractionsinthepatient’smedicalrecordwithin 48 hours.Thisismostlikelytobethepatient’sgeneral/medicalpractitioner,butmayalsoincludeothernon-medicalprescribers.

Clinical Need

3.5 Youmustonlyprescribewherethereisagenuineclinicalneedfortreatment.Youshouldonlyprescribemedicationtomeetidentifiedneedsofpatientsandneverforyourownconvenienceorsimplybecausepatientsdemandthem.


Prescribing and Dispensing / Prescribing and Administering / Prescribing and Reviewing

4.1 Youmustensureseparationofprescribinganddispensingwheneverpossible.Inexceptionalcircumstanceswhereyouarerequiredtoprescribeanddispenseyoumustannotatetheprescriptionaccordingly.Inaddition,asecondsuitablycompetentperson(registeredpharmacist,qualifiedcheckingtechnicianordoctor)shouldbeinvolvedincheckingtheaccuracyofthemedicationprovided.

4.2 You must ensure separation of prescribing and administering activities whenever possible. In exceptionalcircumstanceswhere you are involved in both prescribing and administering a patient’smedication, a secondsuitablycompetentperson(registeredpharmacist,nurseordoctor)shouldbeinvolvedincheckingtheaccuracyofthemedicationprovided.

4.3Withinhospitalpractice,whereapharmacistprescribes,thereisnorequirementforaclinicalcheckbyasecondpharmacistexceptwhensystemicanticancertherapyhasbeenprescribed.

Evidence Based / Formulary

4.4 Youshouldbeawareof,andapply,nationalprescribingguidelinesandlocalformularies.

4.5 Prescribingpracticeshouldbeevidence-basedandrespondto relevantnationalguidance.Where localpolicy /formulary isatvariancewithcurrentnationalguidance,youshouldseekguidance throughclinicalgovernancestructures,inrespectofyourvicariousliability,withinyouremployingorganisation.


Keeping Up to Date

4.6 Itisyourresponsibilitytoremainup-to-datewiththeknowledgeandskillstoenableyoutoprescribecompetentlyandsafely.

4.7 Asapharmacistwhoisrecordedontheregisterasbeingaprescriber,youshouldensurethatyourcontinuingprofessionaldevelopmentisinlinewithyourroleasaprescriber.

Controlled Drugs

4.8 Youmustonlyprescribecontrolleddrugstowhichyouarelegallyentitled.

4.9 Youmustnotprescribeacontrolleddrugforyourselforsomeonewithwhomyouhaveaclosepersonalrelationship.

4.10Thequantityofanycontrolleddrugprescribed(excludingthoseinschedule5)shouldnotexceed28dayssupplyperprescription.Prescriptionsshouldbewrittenaccordingtocurrentlegalrequirements.

Unlicensed /Off Label Medicines

4.11Youcanprescribeunlicensedmedicines,howeverindoingsoyoumust:(a)besatisfiedthatanalternative,licensedmedicinewouldnotmeetthepatient’sneeds.(b)besatisfiedthatthereisasufficientevidencebaseand/orexperienceofusingthemedicinetodemonstrate

itssafetyandefficacy.(c)takeresponsibilityforprescribingtheunlicensedmedicineandforoverseeingthepatient’scare,including

monitoringandanyfollowuptreatment.(d)recordthemedicineprescribedand,whereyouarenotfollowingcommonpractice,thereasonsforchoosing

thismedicineinthepatient’snotes.(e)ensurethatthepatientisawarethatyouareprescribinganunlicensedmedicineforthem

andtherationaleforthis.


4.12Youmayprescribemedicinesforpurposesforwhichtheyarenotlicensed.Whenprescribingamedicineforuseoutsidethetermsofitslicenseyoumust:(a)besatisfiedthatitwouldbetterservethepatient’sneedsthananappropriatelylicensedalternative.(b)besatisfiedthatthereisasufficientevidencebaseorexperienceofusingthemedicinetodemonstrateits

safetyandefficacy.(c)takeresponsibilityforprescribingthemedicineandforoverseeingthepatient’scare,monitoringandany

followuptreatment,orarrangeforanotherprescribertodoso.

Prescribing for family and others

4.13Objectivityisessentialinprovidinggoodcare;independentmedicalcareshouldbesoughtwheneveryouorsomeonewithwhomyouhaveaclosepersonalrelationshiprequiresprescriptionmedicines.Youmustnotprescribeforyourselforforanyonewithwhomyouhaveaclosepersonaloremotionalrelationship.

Remote Prescribing via telephone, email, fax, videolink or website

4.14Inexceptionalcircumstancesitmaybeappropriatetouseatelephoneorothernonface-to-facemediumtoprescribemedicinesandtreatmentforpatients.Suchsituationsmayoccurwhere:(a)youhaveresponsibilityforthecareofthepatient.(b)youareworkinginremoteandruralareas.(c)youhavepriorknowledgeandunderstandingofthepatient’sconditionandmedicalhistory.(d)youhaveauthoritytoaccessthepatient’srecords.


4.15Inallcircumstances,youmustensurethatyou:(a)establishthepatient’scurrentmedicalconditions,historyandconcurrentorrecentuseofothermedications

includingnon-prescriptionmedicines.(b)carryoutanadequateassessmentofthepatient’scondition.(c)identifythelikelycauseofthepatient’scondition.(d)ensurethatthereissufficientjustificationtoprescribethemedicinesortreatmentproposed.Where

appropriateyoushoulddiscussothertreatmentoptionswiththepatient.(e)ensurethatthetreatmentand/ormedicineisnotcontra-indicatedforthepatient.(f)makeaclear,accurate,legibleandcontemporaneousrecordofallmedicinesprescribed.(g)arecompetenttomakeaprescribingdecision.

4.16Whereyoucannotmeetalloftheserequirementsyoumustnotuseremotemeanstoprescribemedicine(s)forapatient.


Communication with patient and monitoring

5.1 Youshouldestablishthepatient’spriorities,preferencesandconcernsandencouragethepatienttoaskquestionsaboutmedicinetakingandtheproposedtreatment.

5.2 Youmustgivepatients,orthoseauthorisingtreatmentontheirbehalf,sufficientinformationabouttheproposedcourseoftreatment,includinganyknownseriousorcommonsideeffectsoradversereactions.Thisistoenablethemtomakeaninformeddecision.

5.3 Youshouldreachagreementwiththepatientontheuseofanyproposedmedication,andthemanagementoftheconditionbyexchanginginformationandclarifyinganyconcerns.Theamountofinformationyoushouldgiveeachpatientwillvaryaccordingtofactorssuchasthenatureofthepatient’scondition,risksandsideeffectsofthemedicine,andthepatient’swishes.

5.4 Youmustagreewiththepatientarrangementsforappropriatefollow-upandmonitoringwhererelevant.Thismayinclude:furtherconsultations;bloodtestsorotherinvestigations;processesforadjustingthedosageofmedicines,changingmedicinesandissuingrepeatprescriptions.


Communication with others

5.5 Youhavearesponsibilitytocommunicateeffectivelywithotherpractitionersinvolvedinthecareofthepatient.Youmustreferthepatienttoanotherprescriberwhenitisnecessarytodoso.

5.6 YoumustinformtheMedicinesandHealthcareproductsRegulatoryAgencyofadversereactionstomedicinesreportedbyyourpatientsinaccordancewiththeYellowCardScheme.YoushouldprovidepatientswithinformationabouthowtoreportsuspectedadversereactionsthroughthepatientYellowCardScheme.

Record Keeping

5.7 Youshouldensurerecordsareaccurate,comprehensive,contemporaneousandaccessiblebyallmembersofaprescribingteam.Recordsshouldincludetheprescriptiondetails,togetherwithrelevantdetailsoftheconsultationwiththepatient.Themaximumtimeallowedbetweenwritingtheprescriptionandenteringthedetailsintothemedicalrecordshould only exceed 48 hoursunderexceptionalcircumstances.

5.8 Insupplementaryprescribing,thedoctorandpharmacistmustshareaccessto,consultand,whereverpossible,

usethesamecommonpatientrecord.


6.1 Youmayissuearepeatprescription,butyoudosointheknowledgethatyouareresponsibleasthesignatoryoftheprescriptionandareaccountableforyourpractice.

6.2 Beforesigningarepeatprescriptionyoumustbesatisfiedthatitissafeandappropriatetodosoandthatsecureproceduresareinplacetoensurethat:(a)thepatientisissuedwiththecorrectprescription.(b)eachprescriptionisregularlyreviewedandisonlyre-issuedtomeetclinicalneed.(c)areviewmusttakeplacefollowingamaximumofsixprescriptionsorsixmonthselapsing.(d)thecorrectdoseisprescribed.(e)suitableprovisionformonitoringeachpatient’sconditionisinplaceandforensuringthatpatientswho

needafurtherexaminationorassessmentdonotreceiverepeatprescriptionswithoutbeingseenbyanappropriateprescriber.

7.1 Youmustnotallowyourownoryouremployers’financialorcommercialinterestsinapharmacytoinfluencethewayyouprescribeforpatients.Youshouldnotacceptanyinducementwhichmayaffectorbeseentoaffecttheadviceyougivepatients.Youmustnotpressurisepatientstouseaparticularpharmacy.

All good practice statements in relation to NHS prescribing are applicable to private prescribing practices.


Documents

A guide to good prescribing practice for prescribing ...€¦ · NHS Education for Scotland | A Guide to Good Prescribing Practice for Prescribing Pharmacists in Scotland The first