Enabling Policy

Question 1

SCope + principles

Answer 1

3. Scope
   The policy applies to all patients and provides guidance for all pharmacists
   in the managed sector (in-patients, out-patients, community hospitals and
   mental health).
   The policy aims to ensure that any changes that need to be made to doses,
   timing of doses or drugs omitted will occur as soon as they are noted by
   the pharmacist and not delayed. The Appendices show specific examples
   of amendments to a prescription or drug administration chart, this is not
   an exclusive list.
   The policy aims to ensure that drugs prescribed reflect Health Board policy,
   provide patient safety benefits and are the most cost effective option.
4. Principles
   Putting patient safety first is the overriding principle underpinning this
   policy. Amendments made to prescriptions by pharmacists must be in the
   interest of patient safety (e.g. correcting prescribing errors, clarification of
   a prescriber’s intention) or to promote cost effective prescribing without
   detriment to the patient.
   This policy enables pharmacists to make prescription amendments in
   accordance with their professional judgement and within their personal
   competence. Examples of minor changes to a patient’s medication and
   suggested therapeutic switches can be found in the appendices. This is not
   an exhaustive list, but can be used to make switches to a patient’s
   medication without contacting the prescriber.
   This policy enables pharmacists to add non-prescription medicines to the
   chart for patients suffering self-limiting conditions. The pharmacist would
   competently assess if the patient clinically benefited from a medicine that
   could be purchased over the counter (e.g. pharmacy only items or general
   sale list) and add to the chart. This includes nicotine replacement therapy
   (NRT). If a patient is attempting to quit smoking, or requires withdrawal
   management during their in-patient stay, the pharmacist would assess the
   patient for the most appropriate NRT product and add to the chart.
   Where there are a multiple number of medicines that require
   amending/additions the pharmacist will consider the need to discuss with
   the prescriber rather than using the enabling policy to amend the
   prescription. Prescribing errors picked up by the pharmacist will be fedback
   directly to the prescriber and immediately rectified, ensuring the patient
   does not come to harm.

Question 2

Examples of chart ammendments:

Answer 2

1. Route of Administration
    The route may be added if left off the prescription.
    Inappropriate or incorrect routes of administration may be changed
   e.g. inhalers prescribed orally.
    Cross through IV route when prescribed PO/IV on regular side of the
   drug chart (be cautious if patient is unable to receive oral
   medication).
2. Timing of Administration
   The timing of administration of medicines may be changed to maximise
   the benefit of medication. For example:
    For optimal efficacy e.g. nitrates, statins, dopaminergic drugs for
   parkinsonism.
    To avoid interaction with food/feed or other medication.
    To minimise side effects e.g. steroids.
    To facilitate drug level monitoring e.g. vancomycin.
    To ensure regularity of administration e.g. antibiotics.
    To reflect what the patient takes at home.
3. Dose and strength of medication
    Dose and/or salt will be amended if necessary, when route of
   administration is changed to ensure there is an equivalent
   bioavailability e.g. IV to oral, tablets to syrup (citalopram, ferrous
   fumarate).
    The strength will be specified when it has been omitted or prescribed
   as “one” or “i” (all routes, but most commonly inhalers).
    To a dose based on weight.
4. Frequency of Administration
   Pharmacists may change doses to the correct frequency. For example:
    Annotate administration boxes with a ‘X’ on the chart to avoid doses
   being given too frequently e.g. methotrexate once weekly,
   bisphosphonates weekly/monthly, fentanyl patches.
    “When required” drugs may have frequencies and maximum daily
   dose added or corrected according to BNF doses appropriate to the
   indication
    Regular oral medication prescribed for incorrect frequency (allowing
   for situations where patient has a reduction in renal or hepatic
   function) will be amended to the patient’s usual frequency.
    Medication (e.g eye drops, inhalers) which is being self-administered
   by the patient at different frequencies to those prescribed, may be
   amended on the prescription to reflect what the patient is actually
   taking.
    Medicines that have been prescribed incorrectly on the “prn” side can
   be transcribed onto the regular prescription e.g. long acting B2 agonist
   and steroid inhalers, nystatin mouthwash, topical antifungals,
   lactulose.
    Divide doses to improve bioavailability e.g. calcium tablets, thiamine.
5. Form/brand of Medication
    Brand of medication will be specified where it is clinically important e.g.
   theophylline, diltiazem, carbamazepine, lithium, phenytoin.
    The preparation will be specified as necessary e.g. the device for inhaled
   medication, cream or ointment.
    The form may be amended to a more appropriate form i.e. tablets to
   liquid.
6. Duplication of Medicines
    A duplicated prescription will be deleted e.g. prescribed on two charts or
   inappropriately on both regular and prn sections of the chart.
    Inappropriate duplication of medicine within the same therapeutic class
   e.g. IV proton pump inhibitor (PPI) plus oral PPI.
7. Drug Interactions
    Amend statin dose when interacting medication commenced/stopped.
    Where appropriate cross through administration box ‘X’ and detail the
   reason on chart/ in medical notes as appropriate e.g. discontinuation of
   statin during a course of clarithromycin or erythromycin.
8. Inappropriate medication
    Cross off drugs when no longer clinically indicated e.g. transfer from
   critical care setting.
    Review appropriateness of drugs with regards to clinical setting.
    Review appropriateness of drugs with regards to patient’s clinical
   condition.
9. Non administration of medication
    Where a patient is continually declining laxatives or analgesics this can
   be switched to the prn side of the chart or stopped completely, if
   appropriate.
10. Duration of prescription
     Medication will be stopped at the appropriate time when clearly indicated
    on the chart or in the therapeutic plan documented in the patient record
    e.g. antibiotic course, chemotherapy regimen, H.Pylori eradication.
11. Supplementary charts/Labels
     A drug will be transcribed on the inpatient chart if it has only been
    prescribed on a supplementary chart e.g. warfarin, insulin, syringe
    driver.
     If pre printed labels are used for IV opioid administration for use only in
    the adult emergency unit or theatres, these may be deleted off the
    prescription when the patient is transferred to a ward.
12. Therapeutic Substitution
    Medication may be switched within a protocol agreed by the medicines
    management group for an individual consultant, directorate or across all
    hospital sites e.g. switch to equivalent therapy when prescribed medicines
    are not available or are non-formulary
13. Omitted Medicines
    Omitted medication that the patient normally takes at home may be
    transcribed onto the in-patient prescription chart. Medication transcribed
    should be signed and dated by the pharmacist in the ‘prescribed by’ box
    and endorsed ‘as at home’ in the special instructions box.
    Reasonable steps must be taken to ensure that a medication that has been
    omitted and has not been deliberately withheld. This should be done by
    checking the medical clerking notes –has the drug been clerked in the
    medication history section of the notes by the admitting doctor, is there
    evidence (written or clinical) to indicate that the drug has been withheld?

Question 3

Switch of medicine/brand/formulation

Answer 3

Dispersible formulations (e.g.
ondansetron, co-codamol,
dicofenac etc)
Standard preparation
Dispersible formulations are more expensive than standard formulations and patients
should be switched back once swallowing difficulties resolve

Lansoprazole fastabs Omeprazole capsules All patients are to be switched if there are no swallow problems or once swallowing
problems resolve. Ensure patient has had no previous intolerance to omeprazole

Prednisolone EC and soluble
tablets
Prednisolone plain tablets

Viscotears, lacrilube, Tears
Naturale eye drops
Hypromellose 0.3% eye
drops
Only for patients newly initiated

Fluconazole liquid Fluconazole capsules All patients are to be switched if there are no swallow problems or once swallowing
problems resolve.

Pegfilgrastim Lipegfilgrastim Patients to be switched from pegfilgrastim to lipegfilgrastim

Co-codamol 30/ 500 Switch to equivalent doses
of separate components;
Paracetamol 500mg – 1g
qds prn
Codeine 30 – 60mg qds
prn
This is to cover a national drug shortage from January 2020 until further notice.
Exemptions as follows; patient not suitable for switch, Patient Group Direction in place,
pre-printed or stamped prescriptions are in use.

Question 4

Change of timing of administration

Answer 4

Anti-diabetic drugs Alter administration to meal times Prevent hypoglycaemia

Eye drops/inhalers/creams Alter administration times according to when
the patient usually takes the medication

Quinolones (Ciprofloxacin,
Levofloxacin)
Alter administration times in relation to
magnesium hydroxide, indigestion mixtures,
iron and sucralfate,
Quinolones are rapidly absorbed, taking them 2 hours before the
interacting medication or 4 hours after should minimize the risk of
admixture in the gut and largely avoid this interaction. Refer to
individual SPC’s for further information.

Colestyramine Alter administration time in relation to other
drugs
Other drugs should be taken at least 1hour before and 4-6 hours
after Colestyramine to reduce possible interference with absorption

Prednisolone oral Alter administration to the morning for once
daily dosing
Avoid alerting affect at night were once daily is indicated.
(Note: indications where more than once daily is indicated )

Dexamethasone oral Change time of last dose to no later than 6pm Avoid alerting affect at night

Selegiline Alter administration time to before 2pm Avoid alerting affect at night

Statins (except atorvastatin) Alter administration time to night time Maximise benefit of therapy

Vancomycin
Gentamicin
Alter administration times to facilitate taking
levels for therapeutic drug monitoring
Refer to ABUHB antibiotic guidelines for monitoring information

Oral bisphosphonates Alter administration times to morning dose to
avoid interaction with food and other
medication
Counsel patients to take medication 30mins before breakfast with
a full glass of water. Sit upright after taking medication.

Question 5

Alteration of dose or frequency of medication prescribed

Answer 5

Oral amoxicillin qds
Oral amoxicillin 500mg tds
Unless part of a H.pylori regimen or otherwise advised by Consultant
Microbiologist

Inhalers Amend to correct dose and strength if
not specified, ensuring dose hasn’t
been changed since admission
Amend according to patients own drugs and/or GP records

Ciprofloxacin oral tds/qds Change to ciprofloxacin oral bd Compliance with licensed dosage

Flucloxacillin oral or IV tds Flucoxacillin oral or IV qds Recommended frequency.

Phenytoin (NG) suspension
100mg tds
Phenytoin NG suspension 300mg on Once daily administration of Phenytoin suspension to reduce potential
for interaction between NG feeds and Phenytoin suspension

Calcium/Vitamin D preparations
containing less than 1g of
calcium and 800units of vitamin
D per daily dose
Change to calcium /vitamin D product
which contains recommended daily
dose of calcium 1g and vitamin D
800units
Recommended daily dose is 1g of calcium and 800units of Vitamin D
(i.e., Calcichew D3 Forte - 2 tablets daily) if being used for
osteoporosis (unless part of clinical trial)

Drugs prescribed which are not
to be given on a daily basis, e.g.
fentanyl patch, weekly
methotrexate, weekly
alendronate
Put an X in the administration
signature box on the medicine chart on
the days which the drug shouldn’t be
given
Ensure that these drugs are not administered more frequently than
intended by the prescriber

Metronidazole PO 500mg
Metronidazole IV 400mg
Metronidazole PO 400mg
Metronidazole IV 500mg
Incorrect dose prescribed for the route of administration

Ciprofloxacin PO 400mg
Ciprofloxacin IV 500mg
Ciprofloxacin PO 500mg
Ciprofloxacin IV 400mg
Incorrect dose prescribed for the route of administration

Question 6

Patient unable to swallow tablets

Answer 6

Prescribed Medication Substitution/Prescription Change Comment
Ferrous sulphate tablets Ferrous fumarate liquid A ferrous sulphate 200mg tablet is approx. equivalent to ferrous fumarate
7.5ml

Liquid preparations that
are classed as
‘Specials’
Crush tablets – but check if medication
can be crushed.
Liquid preparations that are brought in as ‘Specials’ are considerably more expensive than their oral equivalent. Consider crushing tablets but be aware that different brands may differ. E.g. Simvastatin, Thyroxine

Question 7

Medications to be added to drug chart / TTH

Answer 7

Prescribed Medication Substitution/Prescription Change Comment
Glyceryl trinitrate sublingual spray
Add to drug chart and/or TTH if it is not
prescribed for patients with ischaemic
heart disease or patients who use it at
home
Can be added for patients with previous history of ischaemic heart
disease. Prescribe 2 puffs under the tongue for ‘angina type’ pain.

Salbutamol inhaler Add to the drug chart if the patient uses a
Salbutamol inhaler
Ensure strength and device is added to the prescription with the correct number of puffs when required for shortness of breath

Question 8

Examples of non-prescription medicines (P/GSL) that can be added to drug chart

Answer 8

Medicine Type/
Indication
Example of P/GSL Comment

Analgesia Paracetamol Self-limiting paint conditions that can be resolved with when required paracetamol

Laxatives Senna, lactulose, laxido Patients with uncomplicated constipation requiring laxatives that are not contra-indicated

Nicotine Replacement
Therapy (NRT)
All NRT products Patient attempting to quit smoking, or requires withdrawal management during their inpatient stay, the pharmacist would assess the patient for the most appropriate NRT product
and add to the chart.

Antacids Gaviscon Patients with acid indigestion and no gastrointestinal complications requiring antacids after
meals

Moisturising Mouth
Spray
Artificial saliva Added to chart for patients with symptoms of dry, sore or sensitive mouths

Anti-inflammatory
preparations
Difflam mouth spray/
mouthwash
For painful inflammatory conditions of oropharynx, when required mouthwash or throat
spray
Removal of ear wax Olive oil Removal of ear wax with no outer or inner ear complications
Linctus Simple linctus Patients with coughs or sore throats
Vaginal thrush Clotrimazole creams and
pessaries
For non-gynaecological patients presenting with vaginal thrush that can be treated with
clotrimazole

Question 9

Medications to be withheld or stopped on the drug chart / TTH

Answer 9

Paracetamol PRN Cross off the drug chart and TTH if Paracetamol based
products prescribed at maximum dose on regular side

Inhalers and nebuliser
solutions prescribed together
Cross off inhaled LAMA’s for the period the patient is
receiving nebulised Ipratropium.

Statin with specific interacting
antibiotics co-prescribed
Cross statin off the chart for the period the patient is
receiving antibiotic
Avoid simvastatin with clarithromycin, erythromycin and
fusidic acid (cross simvastatin doses off chart, annotating
with a “x”)

Question 10

Recommended prescribing for medical and non-medical prescribers

Answer 10

Prescribe GENERICALLY except
drug groups where branded
prescribing recommended
Drugs which should be prescribed by brand include: Aminophylline MR preps, Tacrolimus, Ciclosporin,
Diltiazem MR preps, Lithium, Mesalazine, Nifedipine MR preps, Theophylline MR preps. For these drugs it is
important to stick with the same brands as different brands have different release characteristics.

Drugs administered intravenously
should be switched to the oral
route as soon as the patient can
take medication orally
Intravenous therapy is associated with increased relative risks of infection to oral treatment, requires more
nursing time and is significantly more expensive than oral treatment.
N.B. Not applicable for anti-infectives for certain indications e.g. severe cellulitis, endocarditis, orthopaedic
infections.

Slow release medication e.g.
Diclofenac SR
Use normal release products unless valid reason to use a slow release product
Use Dispersible formulations and
liquids preparations only when
indicated and switch patients
back to standard preparations
Dispersible formulations and liquids preparations are considerably more expensive than standard preparations.

Medicines of limited value E.g.
glucosamine, or
herbal/homeopathic medication
Always review the use of medicines of limited clinical value. Patients may bring in the own supply should they
wish, but pharmacy will not stock or dispense further supply.

PPIs Long term PPI usage has been linked to increase rates of C-Diff and fractures. Routine prescribing of PPI
should not be undertaken, including patients prescribed steroid. PPI and should only be prescribed in high risk
patients – see steroid policy, and should always have a stop/review date indicated