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Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions

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TITLE: Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions

Document Type:

CLINICAL POLICY

Keywords: ‘Enabling Policy’

Version: Published Date: Review Date:

4.0 29th December 2017 December 2020

Supersedes: Policy for pharmacist amendment of in-patient prescription charts and discharge prescriptions, v3.0, Approved Dec 2014 to Review Dec 2017

Approved by (committee/group):

Drugs and Therapeutics Committee Date Approved: 08-12-2017

Scope: (delete as applicable)

Specialty/ Department: Pharmacy

Evidence Base/ References:

Enabling Protocol for Pharmacists – Portsmouth Hospitals NHS Trust & East Hants Hospital NHS Trust

Pharmacy Enabling Protocol – United Bristol Healthcare NHS Trust

Policy and procedure for Pharmacist amendment of in-patient prescription charts and medication histories – Countess of Chester Hospital NHS Foundation Trust

Lead Division: D&O

Lead Specialty: Medicines Management (Pharmacy)

Author: Cath Fletcher, Clinical Pharmacy Services Manager

Sponsor: Medical Director

Name the documents here or record not applicable Associated Clinical Guideline(s) Not Applicable

Associated Clinical Procedure(s) Procedure for the Endorsement of In-patient Prescription Charts, Discharge and Out Patient Prescriptions

Associated Clinical Pathway(s) Not Applicable

Associated Standard Operating Procedure(s) Not Applicable

Other associated documents e.g. documentation/ forms

Not Applicable

Consultation Undertaken:

Clinical Pharmacy Team meeting 16.11.17

Template control: v1.2 August 2017 (Appendix to Clinical Documents Procedure)


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CONTENTS

Description Page

1

Introduction / Background 2

2

Aims / Objectives / Purpose 3

3

Roles and Responsibilities 3

4

Policy Details (including flowcharts) 4-12

5

Education and Training 12

6

Definitions/ Abbreviations 12

7

Monitoring 12

8

Equality, Diversity and Inclusivity and Impact Assessments 13-14

1

Introduction / Background

Pharmacists commonly identify errors during the process of prescription chart review. To resolve these

pharmacy staff often have to interrupt doctors to request that they make appropriate changes to in-

patient and take-home prescriptions due to the fact that the Medicines Act (1968) does not authorise

pharmacists to change the prescriptions themselves unless they are registered non medical prescribers.

Pharmacists may also leave written notes requesting amendments in the medical records or with

prescriptions, but this does not guarantee that the appropriate changes will be made within a reasonable

time frame. On many occasions there is little advantage in doctors making such changes personally since

they are following the pharmacist’s recommendations. Pharmacists could have an immediate and

significant impact on this by documenting these errors in medical records and where appropriate,

amending the prescription charts directly. In some instances it would be necessary to consult the

patient’s medical team, but for others, minor amendments to medication charts are sufficient. Before

making any alteration, the pharmacist will satisfy themselves by reference to the medical notes or to the

prescriber that perceived discrepancies are not intentionally required by the medical team. If there is

any doubt as to the course of action, the patient’s medical team will be contacted before amendments to

the prescription are made.

Using pharmacists’ skills in this way may help to avoid some medication errors and reduce the number of

doses missed due to unclear or incorrect prescriptions.

Nursing staff should consider amendments to in-patient and take-home prescriptions made under this

policy to carry the same authority as prescriptions written by a doctor.


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2

Aims / Objectives / Purpose

This policy provides guidance on what amendments a pharmacist can make to a medication chart or

discharge prescription without authorisation from the prescribing doctor. The ability to make such

clarifications on prescriptions reduces the chance of medication errors reaching the patient.

Related Trust Documents

Medicines Policy

3

Roles and Responsibilities

This policy is for use by all pharmacists employed by the Trust when providing services to Trust patients.

It will not be used by pharmacists providing services to patients of another Trust under a service level

agreement e.g. hospice patients and oncology patients. This policy is intended for use by ward

pharmacists with full access to patients’ medical notes although some minor amendments may be made

by the dispensary pharmacist. Pharmacists should be competent in medication history taking and be

familiar with the pharmaceutical and medical action plan for the patient concerned. They must have

passed their ‘professional screening’ validation and their ‘accuracy checking’ validation. Locum

pharmacists may not amend prescriptions under this policy unless authorised by the Clinical Pharmacy

Services Manager. This authorisation will be documented in the individuals personnel file.

The pharmacist will be accountable for any amendments made and these amendments should be made

in accordance with this policy. Pharmacists must always act within their level of competence. Their

primary concern must be the well-being and safety of the patient. Serious errors/omissions must be

recorded using the Trust incident reporting system (Datix).

All changes to the prescription chart made by a pharmacist should be

in green ink

written in capital letters

initialled

dated

If this cannot be achieved clearly and unambiguously on the prescription, then the whole prescription

should be re-written and signed by a doctor. It is important to consider the balance between the

pharmacist correcting prescriptions in the interest of the patient and the educational value of informing

junior doctors of their errors. To this end the pharmacist should consider whether it is necessary to

inform the appropriate doctor of any change(s) made to a prescription.

Authorisation to follow this procedure will be given by the Clinical Pharmacy Services Manager.


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4

Policy Details (including Flowcharts)

The following tables lay out the framework for pharmacist amendment of medication charts/discharge

prescriptions and give specific guidance as to the range of actions that may be carried out in specific

situations. The pharmacist must always be satisfied that any change to a patient’s medication is not

deliberate before they make any amendments.

Pharmacists must remember that it is Trust policy to re-write prescriptions rather than amend them for

any changes in dose. Any endorsements will be made in line with the Pharmacy Department’s “Procedure

for the Endorsement of In-patient Prescription Charts, Discharge and Out Patient Prescriptions”.

The pharmacist must ensure that, where appropriate, any actions are documented and signed for in the

patient’s medical record including documenting the name of the prescriber involved in any amendments.

All amendments to a prescription chart must be signed and dated by the pharmacist making the

amendment. All amendments made on the Trust e-discharge system must be documented in the

amendments section along with the name of the prescriber consulted where appropriate.

Crossing off of any medication must be done as per Trust Medicines Policy. Medical staff must be

informed of any rewritten prescriptions which need to be signed to ensure this is done in a timely

fashion. All prescriptions written and signed by a pharmacist must have ‘Pharmacist Enabling Policy’

written after the signature.

All Pharmacists

1. Incorrect medicine/Omitted medicine

Problem Action by pharmacist Who can do this?

Item prescribed on

inpatient (IP) chart that

patient is no longer

taking

Pharmacist to clarify with medical

team that the item is not required

unless this is obvious. Once this is

done they can cross off the

prescription as per Trust

Medicines Policy, sign and date

the amendment and annotate

with the name of the prescriber

contacted. The reason for

stopping the item must be

documented in the medical notes

All ward pharmacists

Item prescribed on

discharge prescription

(TTO) that patient is no

longer taking and is not

prescribed on the IP

chart

Pharmacist to clarify with medical

team that the item is not required

unless this is obvious. On the Trust

e-discharge system the item can

be deleted from the TTO and

details recorded on the

amendments tab. The amendment

should be signed and dated with

the name of the prescriber

documented where necessary.

All pharmacists


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Duplicated items e.g.

generic and branded

formulation prescribed

The pharmacist should check what

the patient has been taking and

cross off one prescription as per

Trust Medicines Policy, annotate

“duplicate” and sign and date the

amendment. On the Trust e-

discharge system the item can be

deleted from the TTO and details

recorded on the amendments tab

All pharmacists

Dual items prescribed

with similar therapeutic

effect but different

routes i.e. ipratropium

nebules and tiotropium

inhaler, thiamine tablets

and Pabrinex® injection

The pharmacist should clarify

which item is current therapy and

cross off the doses of the item

temporarily on hold

All pharmacists

When medication for

parenteral

administration at home

is prescribed on a TTO

and the additional

solutions for

reconstitution and

dilution are not

prescribed.

The pharmacist may supply these

items on discharge or out-patient

(OP) prescriptions as required.

The additional fluids and diluents

will be those specified in either

the medicine’s ‘Summary of

Product Characteristics’, the

University College London (UCL) IV

guide, the Trust OPAT guidelines

or the current British National

Formulary.

All additional items will be added

to the TTO record or OP

prescription

All pharmacists

Glyceryl Trinitrate spray /

tablets not on

medication chart and

patient usually on at

home.

Add to medication chart unless

contra-indication apparent from

medical notes (e.g. aortic

stenosis). Document in medical

records. Pharmacist may sign

prescription.


Salbutamol / Terbutaline

inhalers not prescribed

on medicine chart and

patient usually on at

home.

Add to medication chart in ‘as

required’ section unless contra-

indication apparent from medical

notes. Document in medical

records. Pharmacist may sign

prescription.



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Patient is on

combination preparation

but only one medicine

has been prescribed e.g.

patient on Seretide but

Dr prescribed fluticasone

only

Annotate chart with details of

combination prep – if necessary

for clarity rewrite the prescription.

If there is any possibility that the

product may have been changed

check with Dr first


2. Dose/Route/Frequency incorrect


Dose/formulation unclear

e.g. the dose may be

prescribed as “1 tablet” when

the medicine comes in more

than one strength

Pharmacist to clarify on the

prescription chart and initial

and date any amendment. If

the intention is unclear the

pharmacist should clarify with

the prescriber before amending

the prescription chart.


Route of administration

incorrect (i.e. not possible)

e.g. oral specified for a

sublingual tablet, insulin

prescribed orally

Pharmacist can amend

prescription chart, initial and

date amendment

All pharmacists

Inappropriate, unclear or

ambiguous modified release

preparation prescribed

Pharmacist to amend, or

rewrite on medication chart as

appropriate. If a new

prescription is written this must

be left for the doctor to sign


Statins prescribed in the

morning

Change to night-time dosing

(unless atorvastatin or

rosuvastatin which may be

taken at any time of the day).

Only exception is the occasional

patient who takes their statin in

the morning to assist with

compliance. Chart must be

amended as below, initialled

and dated by pharmacist

All pharmacists


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Statin prescribed at the same

time as a macrolide

Pharmacist can cross out statin

doses during the antibiotic

course

All pharmacists

Course of medicine

completed but still prescribed

on chart or TTO

Pharmacist to stop medication

on chart and sign and date

amendment. This can be done

without consultation in the

case of medicines with fixed

course lengths e.g. naseptin

/octenisan. The prescriber

should be contacted to confirm

the course length if this can be

variable e.g. prednisolone,

antibiotics. Once clarified with

a doctor the pharmacist can

amend the prescription. In the

case of TTOs the pharmacist

can remove an item from a TTO

if the course is already

complete on the drug chart

All pharmacists

Course length missing from

TTO

If course length is clear on

inpatient prescription chart the

pharmacist can add to the TTO.

If the course length is unclear

the pharmacist must discuss

with medical team first

All pharmacists

Patient on regular compound

paracetamol preparations,

and also on when required

paracetamol preparations

Pharmacist to amend

prescriptions to avoid overdose

of paracetamol. No

documentation required in the

medical record but chart must

be annotated, initialled and

dated by pharmacist

All pharmacists

Once weekly preparations

prescribed as once daily e.g.

alendronate, methotrexate.

Also include patches applied

Pharmacist to clarify the usual

day(s) of administration and

amend the chart accordingly by

crossing through the

All pharmacists


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every few days e.g. fentanyl,

buprenorphine, HRT

administration boxes. Add

methotrexate sticker for all

methotrexate prescriptions and

record all examples of daily

methotrexate prescriptions on

Datix incident reporting system

"When required"

prescriptions for items such

as clotrimazole cream,

aciclovir cream, nystatin

suspension. NB: These are

unlikely to be therapeutically

effective unless given

regularly.

Pharmacist to discontinue PRN

prescription and prescribe on

regular side of the medication

chart. No documentation in the

medical record is required and

the chart may be signed by a

pharmacist


Maximum dose of “when

required” medicines not

stated

Pharmacist can add maximum

dose where appropriate

All pharmacists

3. Prescription Therapy that may result in significant patient harm


Prescribed therapy presents an

immediate danger to the

patient e.g. penicillin

prescribed to a patient who has

previously suffered an

anaphylactic reaction to

penicillin, or methotrexate

prescribed daily rather than

weekly

Pharmacists to liaise with

nursing staff to ensure the

medicine is not given and

discontinue it from the

medication chart. Immediate

attempts must then be made

to contact the prescriber and

the response documented in

the medical record. A Datix

incident form should also be

completed

All pharmacists

4. Missing devices and strengths


Inhaler strengths missing Endorse strengths

All pharmacists

Inhaler devices incorrect Endorse device, include any

additional aids used, e.g.

volumatic

All pharmacists


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Inhaler doses missing Endorse frequency and number

of doses, e.g. 2 puffs

All pharmacists

Co-codamol prescribed with no

strength

Pharmacist to add “8/500” or

“30/500” if part of patient’s

usual medication history. If not,

discuss with Dr first.


Insulin prescriptions lacking

information about strength,

device etc

Check medical notes first to

ensure change is not

deliberate. Pharmacist to

amend medication chart as per

medication history.

All pharmacists

Items prescribed on additional

charts but not on main

medicine chart, e.g. insulin,

warfarin, antibiotic infusions

etc.

Pharmacist can add to main

medication chart and sign

prescription. Dose should be

specified as ‘APC’

All pharmacists

5. Dosage forms


Patient cannot swallow

solid medication

Pharmacist to convert to

equivalent doses of liquid

preparation where possible. Any

change in preparation e.g. ferrous

sulphate tablets to ferrous

fumarate liquid requires a new

prescription to be written. If the

dose is clinically equivalent the

pharmacist can sign the

prescription

All pharmacists

Incorrect dose

prescribed on chart

when formulation

changed.

e.g. metronidazole PO

prescribed as 500mg

TDS, ciprofloxacin PO

prescribed as 400mg BD

If the item is new the pharmacist

must clarify with the doctor which

route is required. Prescription

must be rewritten but can be

signed by the pharmacist.

All pharmacists


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6. Miscellaneous


Allergy information not

complete

Pharmacist to add to prescription

chart as per Trust Medicines Policy


Multiple charts in use

but it is not specified 1

of 2, 2 of 2 etc on the

front

Pharmacist to add information to

prescription chart

All pharmacists

Post Diploma Pharmacists

1. Incorrect medicine/Omitted medicine

Transcription errors occurring

when prescription charts are re-

written or TTO is prescribed.

Pharmacist may correct obvious

discrepancies. If the intention is

unclear the pharmacist must check

with the prescriber before

amending the prescription chart or

TTO. If necessary the prescription

should be rewritten and signed by

the pharmacist

Post diploma pharmacists

Topical preparations not on

medication chart (and patient

usually uses at home) (e.g. eye/ear

drops, nasal spray, creams). Usual

regime must be confirmed with

patient before prescribing. If this is

not possible check with Dr first.



medical notes. Document in

medical records. Pharmacist may

sign prescription

.


OTC (Over The Counter) medicines

that patient normally uses at

home.

These may be added to the

prescription chart when not

contra-indicated. Pharmacist may

sign prescription if verbal

agreement is obtained from

prescriber.


Contraceptive Pill/ HRT not on

medication chart (and patient

usually uses at home).



medical notes (e.g. admitted with

possible DVT/PE, surgery). Check

VTE risk assessment document.

Document in medical records.

Pharmacist may sign prescription if



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verbal agreement is obtained from

prescriber. If adding in a

contraceptive pill or HRT the VTE

risk assessment should be redone

and the pharmacist must ensure

the doctor has prescribed

enoxaparin as appropriate

Non formulary oral iron

preparations and calcium/vitamin

D preparations

Convert to the nearest equivalent

dose of ferrous fumarate or Adcal

D3 unless patient has plenty of

their own supply. Pharmacist can

sign prescription


2. Dose/Route/Frequency incorrect

Isosorbide mononitrate prescribed

at 08.00 and 18.00 or 08.00 and

22.00. Doses are not usually given

after 14.00 due to the need for a

nitrate free period.

Check what time the patient

usually takes their tablets at home.

Change dosing times to 08.00 and

14:00 where appropriate. Chart

must be annotated, initialled and

dated by pharmacist. Occasionally

within cardiology different dose

schedules are used for patients

with poor angina control. In such

cases contact the prescriber

before any amendment is made


Diuretics prescribed 08:00 and

22:00 - night time doses are likely

to disturb sleep

Change to 08:00 and 14:00 unless

patient is catheterised or

specifically stated in medical

records or by the patient. Chart

must be annotated, initialled and

dated by pharmacist


Patient has a specific routine that

they wish to adhere to and which

is agreed to be clinically

appropriate, e.g. timing of

Parkinson’s medicines

Check in medical notes to ensure

prescription has not been

deliberately changed. Dosing

schedule amended. Account must

be taken of doses already given to

ensure there is no duplication of

doses on same day. Chart must be

rewritten and signed by the

pharmacist and actions

documented in the medical

record. Pharmacist should also

discuss with nursing staff



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Medicines prescribed not in

accordance with standard

frequency of administration (e.g.

amoxicillin prescribed QDS,

clarithromycin prescribed TDS)

Pharmacist to clarify whether this

is deliberate or important e.g.

reduced doses in renal failure. If

not, pharmacist to amend dosing

frequency on medication chart and

initial and date the amendment


Medicines prescribed at

inappropriate times, e.g. in

relation to meals or other

medicines, leading to potential

adverse drug reactions or

treatment failure e.g. metformin /

Creon not at mealtimes,

cholestyramine at the same time

as other medicines, iron at the

same time as ciprofloxacin,

zopiclone in the morning

Pharmacist must check with

patient what their usual routine is

especially in relation to

antidiabetic medicines. Pharmacist

can change administration times.

Account must be taken of doses

already given to ensure there is no

duplication of doses on same day.

Documentation may be required in

the medical notes depending on

the degree of alteration but the

prescription chart must be

rewritten and signed by

pharmacist.


5

Education and Training

All new pharmacists will be trained and assessed on induction. Band 6 pharmacists will have their work

regularly reviewed as part of their post-graduate clinical diploma assessment process.

6

Definitions/ Abbreviations

The Trust Sherwood Forest Hospitals NHS Foundation Trust.

Staff All employees of the Trust including those managed by a third party organisation

on behalf of the Trust.

Dispensary pharmacist Pharmacist responsible for screening prescriptions in the dispensary. This

individual will have no access to the patient’s medical records

Ward Pharmacist Pharmacist responsible for providing a pharmacy service to a ward area. This

individual will have access to a patient’s medical records and can talk to patients

and medical staff face to face

Post Diploma Pharmacist Pharmacist with at least 2 years’ experience post registration who has completed

a post graduate qualification in clinical pharmacy or medicines management


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7

Monitoring

7.0 MONITORING COMPLIANCE AND EFFECTIVENESS

Minimum Requirement

to be Monitored

(WHAT – element of compliance or effectiveness within the

document will be monitored)

Responsible Individual

(WHO – is going to monitor this element)

Process for Monitoring

e.g. Audit

(HOW – will this element be

monitored (method used))

Frequency of

Monitoring

(WHEN – will this element be monitored

(frequency/ how often))

Responsible Individual or Committee/

Group for Review of Results

(WHERE – Which individual/

committee or group will this be reported to, in what format (eg

verbal, formal report etc) and by who)

All amendments made by pharmacy staff are in line with policy requirements

Clinical Pharmacy Services Manager

Audit Annually Verbal report to Drugs & Therapeutics Committee

8

Equality, Diversity and Inclusivity and Impact Assessments

Equality Impact Assessment (EqIA) Form (please complete all sections)

Guidance on how to complete an EIA

Sample completed form

Name of service/policy/procedure being reviewed: Policy for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions

New or existing service/policy/procedure: Existing

Date of Assessment:17.11.17

For the service/policy/procedure and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)

Protected

Characteristic

a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups’ experience? For example, are there any known health inequality or access issues to consider?

b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening?

c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality

The area of policy or its implementation being assessed:

Race and Ethnicity: None NA None

Gender:

None NA None

Age:

None NA None

Religion: None NA None

Disability:

None NA None

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?ContentId=49233

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?ContentId=49236


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Sexuality:

None NA None

Pregnancy and Maternity:

None NA None

Gender Reassignment: None NA None

Marriage and Civil Partnership:

None NA None

Socio-Economic Factors (i.e. living in a

poorer neighbourhood / social deprivation):

None NA None

What consultation with protected characteristic groups including patient groups have you carried out? Not needed

What data or information did you use in support of this EqIA? None

As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No

Level of impact From the information provided above and following EqIA guidance document, please indicate the perceived level of impact: Low Level of Impact For high or medium levels of impact, please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting.

Name of Responsible Person undertaking this assessment: Cath Fletcher

Signature:

Date: 17.12.17