what to do if a dr was continuing to prescribing a medication with severe side effects
Appropriate Prescribing of Medications: An Eight-Step Approach
Am Fam Physician. 2007 January xv;75(2):231-236.
Patient information: Encounter related handout on using medicines wisely, written past the authors of this article.
Article Sections
- Abstract
- Step 1. Evaluate and Clearly Ascertain the Patient'south Problem
- Step 2. Specify the Therapeutic Objective
- Step three. Select the Appropriate Drug Therapy
- Pace 4. Initiate Therapy with Appropriate Details and Consider Nonpharmacologic Therapies
- Step 5. Give Information, Instructions, and Warnings
- Footstep 6. Evaluate Therapy Regularly
- Step 7. Consider Drug Cost When Prescribing
- Step 8. Use Computers and Other Tools to Reduce Prescribing Errors
- References
A systematic arroyo advocated by the World Health Organisation can help minimize poor-quality and erroneous prescribing. This vi-step approach to prescribing suggests that the physician should (1) evaluate and clearly define the patient'southward trouble; (2) specify the therapeutic objective; (3) select the appropriate drug therapy; (4) initiate therapy with advisable details and consider nonpharmacologic therapies; (5) requite information, instructions, and warnings; and (6) evaluate therapy regularly (e.k., monitor treatment results, consider discontinuation of the drug). The authors add 2 additional steps: (7) consider drug cost when prescribing; and (8) employ computers and other tools to reduce prescribing errors. These eight steps, along with ongoing self-directed learning, etch a systematic approach to prescribing that is efficient and applied for the family medico. Using prescribing software and having access to electronic drug references on a desktop or handheld computer can besides improve the legibility and accuracy of prescriptions and help physicians avoid errors.
In 2001, persons in the United States younger than 65 purchased a hateful of x.viii prescription drugs and those 65 or older purchased a mean of 26.5 prescription drugs.1 With that level of prescribing, it is not surprising that errors occur. Minimizing such errors through a systematic approach is recommended by national and international authorities2–five and has fatigued the attention of consumer advocates.half dozen Review each of the following clinical scenarios for potential prescribing errors, and consider if y'all take a strategy for avoiding such errors in your own prescribing. All of the scenarios take place during a typical day at a family unit practice part; scenarios 1 through iv are phone messages given to you by the nurse and scenario v is a patient in the waiting room.
SORT: KEY RECOMMENDATIONS FOR Practice
| Clinical recommendation | Testify rating | References |
|---|---|---|
| Use a systematic arroyo to prescribing to decrease errors, aid patients avert agin events, and better intended outcomes. | C | 2, ten |
| Discontinue apply of abbreviations and non-English characters in prescription writing. | C | 13 |
| Provide patient education at the time of prescribing to improve patient adherence to pharmacotherapy. | C | 18 |
| Use electronic prescribing tools to prevent errors caused by drug interactions and poor handwriting. | C | 23, 24 |
Scenario 1: A five-yr-old boy who had pink middle and a clear ocular discharge was started on antibody drops four days ago and initially improved, but today the redness and irritation has returned.
Scenario 2: A patient seen yesterday for a sleep-depriving cough was started on antibiotics, but the cough withal kept her awake last night.
Scenario iii: A by and large healthy 70-year-sometime woman who takes nonsteroidal anti-inflammatory drugs (NSAIDs) for her osteoarthritis at present reports talocrural joint edema. In your absence, a colleague had started her on a calcium channel blocker for newly diagnosed hypertension.
Scenario 4: A 20-twelvemonth-old woman with sinus hurting who was prescribed a fluoroquinolone by the overnight phone call physician called this forenoon to asking a cheaper alternative medication.
Scenario 5: A 29-year-erstwhile woman has presented to the function. She is obese, has type 2 diabetes, and is reporting elevated claret pressures measured at home and at work. You are considering starting her on an angiotensin-converting enzyme inhibitor.
This article summarizes and adapts the recommendations from the Earth Health Organization'due south (WHO) Guide to Practiced Prescribing.2 The employ of these guidelines should aid physicians to minimize prescription errors and improve prescribing quality.
Step 1. Evaluate and Clearly Ascertain the Patient's Problem
- Abstract
- Step i. Evaluate and Clearly Define the Patient's Problem
- Pace 2. Specify the Therapeutic Objective
- Step 3. Select the Appropriate Drug Therapy
- Step 4. Initiate Therapy with Appropriate Details and Consider Nonpharmacologic Therapies
- Step 5. Give Information, Instructions, and Warnings
- Step 6. Evaluate Therapy Regularly
- Footstep 7. Consider Drug Cost When Prescribing
- Step 8. Utilise Computers and Other Tools to Reduce Prescribing Errors
- References
In scenario ane, the child treated with antibiotic drops probable had a viral conjunctivitis that did non need specific treatment.vii If the kid has become sensitive to the prescribed medication, his recurrent symptoms represent morbidity related to an unnecessary prescription.
In scenario 4, it is causeless that the woman with sinus pain was diagnosed with a bacterial infection over the phone on the basis of a symptom, rather than as part of an examination. Prescribing a quinolone to a woman of childbearing historic period exposes her kid to serious teratogenic side effects if she turns out to exist pregnant. Defining the problem conspicuously every bit "sinus pain in a adult female of childbearing age" might take led to a more than advisable management course.
Step 2. Specify the Therapeutic Objective
- Abstract
- Step 1. Evaluate and Clearly Ascertain the Patient's Trouble
- Step 2. Specify the Therapeutic Objective
- Step 3. Select the Advisable Drug Therapy
- Step iv. Initiate Therapy with Appropriate Details and Consider Nonpharmacologic Therapies
- Stride v. Give Information, Instructions, and Warnings
- Stride half dozen. Evaluate Therapy Regularly
- Step 7. Consider Drug Cost When Prescribing
- Step viii. Utilise Computers and Other Tools to Reduce Prescribing Errors
- References
Specifying the therapeutic objective allows physicians to direct prescribing to a clear goal with expected outcomes. This tin can be illustrated using several of the clinical scenarios. In scenario v, which involves the woman with diabetes and the added diagnosis of hypertension, 1 articulate therapeutic objective would be to obtain sustained blood pressure readings of less than 130/80 mm Hg.8
In scenario ii, which involves the patient with nocturnal cough, the objective of restoring slumber was not met with the antibiotic prescription; the antibody was most probable unneccessary.9 For the adult female with sinus pain (scenario 4), even if an antibiotic was necessary, prescribing a medication that the patient could non afford clearly missed the therapeutic objective.
Other common examples of nonspecific prescribing include using benzodiazepines for insomnia without investigating the cause, and using analgesics without diagnosing the underlying source of pain. Setting articulate therapeutic goals is particularly of import in weather that have treatment objectives that vary depending on adventure factors (due east.g., dyslipidemia in patients with or without diabetes).
Step 3. Select the Advisable Drug Therapy
- Abstruse
- Step 1. Evaluate and Clearly Ascertain the Patient's Problem
- Step 2. Specify the Therapeutic Objective
- Step 3. Select the Appropriate Drug Therapy
- Step 4. Initiate Therapy with Appropriate Details and Consider Nonpharmacologic Therapies
- Step 5. Give Information, Instructions, and Warnings
- Step 6. Evaluate Therapy Regularly
- Step seven. Consider Drug Toll When Prescribing
- Stride eight. Employ Computers and Other Tools to Reduce Prescribing Errors
- References
The WHO guide suggests that physicians develop a formulary of personal drugs (P-drugs).2 P-drugs are constructive, inexpensive, well-tolerated drugs that physicians regularly prescribe to treat common problems. Detailed guidance on developing a personal formulary can be plant in the WHO transmission, which is available at http://whqlibdoc.who.int/hq/1994/WHO_DAP_94.11.pdf.2 The STEPS (Safety, Tolerability, Effectiveness, Price, Simplicity) framework also can aid with building a P-drug formulary.x
The P-drug and STEPS approaches tin can be shown using the example of the woman with diabetes and the added diagnosis of hypertension presented in scenario v. Generic formulations of hydrochlorothiazide (Esidrix), lisinopril (Zestril), metoprolol succinate (Toprol XL), and metoprolol tartrate (Lopressor) are all potential P-drug medications. Except for metoprolol tartrate, all of these drugs can be administered in one case daily. Lisinopril offers both blood pressure level control and prevention of diabetic complications,11 just information technology is contraindicated if the patient is not using a reliable form of birth command. It also is more than expensive than hydrochlorothiazide. Metoprolol reduces claret pressure level and diabetic complications.11 However, metoprolol tartrate requires twice-daily dosing, which tin can touch on adherence, and metoprolol succinate is typically more than expensive. Hydrochlorothiazide is the cheapest, but it does not carry the actress do good of avoidance of diabetic complications. A STEPS cess (Table i10) will rest the convenience, effectiveness, and benefit of each drug for a particular patient. This analysis may pb to different drug selections for different patients.
TABLE 1
STEPS Framework: An Example of How to Select a Personal Drug (P-Drug) for a Patient
| Drug * | Safety | Tolerability | Effectiveness | Price | Simplicity |
|---|---|---|---|---|---|
| Hydrochlorothiazide (Esidrix) | F | F | F | SF | SF (once daily) |
| Lisinopril (Zestril) | V† | F | SF | V | SF (in one case daily) |
| Metoprolol tartrate (Lopressor) | F | F | SF | F | F (twice daily) |
| Metoprolol succinate (Toprol XL) | F | F | SF | U | SF (in one case daily) |
In scenario 3, which involves the patient with osteoarthritis, inappropriate prescribing may have been harmful. Her hypertension may be a side effect of the NSAID she was receiving, and her ankle edema could be a side effect of the antihypertensive she was receiving. Maybe the NSAID should accept been discontinued and an adequate dose of acetaminophen, taken three or four times daily, should have been prescribed for her pain rather than adding some other medication and inducing a second side effect. This example illustrates that it is important to consider a patient'due south age, chronic disease status, and other medications currently beingness taken before choosing a handling.
Stride 4. Initiate Therapy with Advisable Details and Consider Nonpharmacologic Therapies
- Abstract
- Pace 1. Evaluate and Conspicuously Define the Patient'south Problem
- Pace 2. Specify the Therapeutic Objective
- Stride 3. Select the Appropriate Drug Therapy
- Step 4. Initiate Therapy with Appropriate Details and Consider Nonpharmacologic Therapies
- Step 5. Give Information, Instructions, and Warnings
- Step vi. Evaluate Therapy Regularly
- Pace 7. Consider Drug Toll When Prescribing
- Pace 8. Utilize Computers and Other Tools to Reduce Prescribing Errors
- References
Prescriptions should be clear, legible, and written in evidently English. The National Coordinating Council on Medication Fault Reporting and Prevention recommends eliminating most abbreviations for medication instructions, such as qd (daily), qid (4 times daily), and qod (every other day). They also recommend eliminating abbreviations for drug names, such as MSO4 (morphine sulfate).12 To exist effective, prescribers should eliminate nonstandard abbreviations that are easily misread, such equally non-English characters (eastward.g., μ).13 Using plain English for all prescription writing allows the patient to read and draw attending to any errors.14
Prescriptions should include specific indications for anticipated duration of therapy. For instance, write out "equally needed for severe back pain" instead of using the abbreviation prn (as needed). Adding the statement, "instructions in Spanish delight," to the prescription (possibly implemented as a check box on the prescription grade) offers a safe net for physicians and pharmacists to reduce prescribing errors for Spanish-speaking patients.fourteen Patients taking complex prescriptions similar prednisone tapers may need additional written instructions, equally may visually impaired patients who take difficulty reading medicine canteen labels. Physicians should consider reducing transcription errors by prescribing electronically.12,14
Nonpharmacologic therapy remains an of import handling option. In scenario v, the woman with diabetes and the added diagnosis of hypertension may not need medication if she loses weight and exercises. A patient with chronic headaches may respond to relaxation training, and a patient with insomnia may meliorate with ameliorate sleep hygiene.xvi Studies have shown that physicians often write prescriptions of doubtful benefit because of perceived pressure to prescribe medications. All the same, these perceptions may exist inaccurate. Asking a patient directly near therapeutic goals may shed light on his or her willingness to utilize nonpharmacologic options when available.17
Pace 5. Give Data, Instructions, and Warnings
- Abstract
- Pace 1. Evaluate and Clearly Define the Patient'southward Problem
- Step 2. Specify the Therapeutic Objective
- Footstep 3. Select the Appropriate Drug Therapy
- Step 4. Initiate Therapy with Appropriate Details and Consider Nonpharmacologic Therapies
- Footstep 5. Give Information, Instructions, and Warnings
- Step 6. Evaluate Therapy Regularly
- Pace 7. Consider Drug Toll When Prescribing
- Stride 8. Use Computers and Other Tools to Reduce Prescribing Errors
- References
Physicians should educate patients well-nigh the intended use, expected outcomes, and potential side effects for each prescribed medication.18 Although it is impossible to describe each side result for a given medication, it is important to address the common and the rare but serious ones. Physicians must describe how the medication should (and should not) be administered, including whatsoever important relationships to food, fourth dimension of day, and other medications being taken by the patient.
In scenario 5, the woman with diabetes and the added diagnosis of hypertension should be informed that lisinopril will reduce her blood pressure level, protect her kidneys, and could cause a rare but serious reaction called angioedema that demands immediate medical attention. She should likewise know that approximately one in 15 patients experiences cough with or without altered gustation awareness. When communicating take a chance, use absolute numbers (e.g., one in fifteen), rather than percentages, probabilities, odds, or likelihoods, to brand it easier for the patient to understand.
Physicians also may want to highlight special drug-related information such as avoiding alcohol when taking metronidazole (Flagyl), staying out of the sun when taking tetracycline, and the possibility of sexual side furnishings with selective serotonin reuptake inhibitors. Explaining that certain side effects are time-express can help prevent a patient from discontinuing a needed therapy.fourteen Patients can demonstrate their understanding of the medication by repeating back pertinent information. At the end of the visit, the prescriber should ensure that the patient knows when to return for monitoring and whether therapy continues afterwards this single prescription.
Pace half dozen. Evaluate Therapy Regularly
- Abstract
- Step 1. Evaluate and Clearly Define the Patient's Problem
- Stride two. Specify the Therapeutic Objective
- Step 3. Select the Appropriate Drug Therapy
- Step 4. Initiate Therapy with Appropriate Details and Consider Nonpharmacologic Therapies
- Step 5. Give Information, Instructions, and Warnings
- Stride 6. Evaluate Therapy Regularly
- Stride 7. Consider Drug Cost When Prescribing
- Footstep viii. Use Computers and Other Tools to Reduce Prescribing Errors
- References
Systematically reviewing medications at every visit allows the prescriber to monitor treatment effectiveness and reduce problems, particularly in older patients who are most susceptible to polypharmacy.nineteen A medication review may include revisiting a diagnosis, evaluating possible side effects, searching for drug interactions, and ceasing unnecessary medications. For instance, an antihypertensive may be discontinued after a patient loses weight, or an NSAID for back pain may be stopped after continued exercise and physical therapy.
A review also helps avoid the prescribing cascade, which involves a physician adding additional drugs to a patient'south regimen to treat side effects of other medications.xx In scenario iii, the patient's ankle edema may be a side effect of the calcium channel blocker that was prescribed to care for her hypertension. The hypertension may be a side effect of her pain medication. Planning regular monitoring for certain medications is of import. In scenario five, if the patient is on lisinopril, she will need follow-up serum chemistries to assess for hyperkalemia or increased serum creatinine.
Step 7. Consider Drug Toll When Prescribing
- Abstract
- Step 1. Evaluate and Conspicuously Define the Patient's Trouble
- Step 2. Specify the Therapeutic Objective
- Step three. Select the Appropriate Drug Therapy
- Step four. Initiate Therapy with Advisable Details and Consider Nonpharmacologic Therapies
- Pace five. Give Data, Instructions, and Warnings
- Step half-dozen. Evaluate Therapy Regularly
- Footstep 7. Consider Drug Cost When Prescribing
- Step 8. Use Computers and Other Tools to Reduce Prescribing Errors
- References
Physicians often fail to consider cost as an of import prescribing factor.21 Among Medicare beneficiaries, 56 percentage use prescription medications costing more than $500 per yr, and 38 percent crave medications costing $1,000 or more than per year.22 In 1 study, two thirds of older patients planned to underuse their medications considering of cost.21 Fifty-fifty for patients not requiring chronic medications, filling a prescription that costs the equivalent of several days' pay can be an unpleasant daze.
Asking about a patient'southward access to a medical prescription card can help to avoid formulary conflicts and delays in starting therapy. Prescribing and drug reference software tin inform physicians and patients near medication costs and coverage on the insurance visitor'southward formulary (Table 2). A local pharmacist besides can propose alternatives that subtract price.
Footstep 8. Use Computers and Other Tools to Reduce Prescribing Errors
- Abstract
- Step 1. Evaluate and Clearly Define the Patient's Problem
- Step two. Specify the Therapeutic Objective
- Step 3. Select the Appropriate Drug Therapy
- Step four. Initiate Therapy with Appropriate Details and Consider Nonpharmacologic Therapies
- Step 5. Give Data, Instructions, and Warnings
- Step 6. Evaluate Therapy Regularly
- Pace 7. Consider Drug Cost When Prescribing
- Step 8. Utilise Computers and Other Tools to Reduce Prescribing Errors
- References
Optimal apply of the first seven guidelines requires a working knowledge of current medications and keeping upward to date on new drugs. The sources described in Tabular array 2 provide more than objective, prove-based data than pharmaceutical representatives or advertisements. Given the pace of change in pharmacotherapeutics, physicians should use continuously updated software for their paw-held or desktop computers and are strongly brash to consider using electronic prescribing programs.23,24
Physicians also tin admission therapeutic guidelines from sources like the National Guideline Clearinghouse, which can be establish at http://www.guidelines.gov. These sources provide clear statements about the strength of prove supporting their recommendations. Testify indicates that many new medications offer little or no benefit over drugs that may already be in a personal formulary. More than x percent of new drugs on the market in the last 25 years have earned a blackness box warning or have been withdrawn from the market. For this reason, physicians should not prescribe new medications until they have been demonstrated to be safer or more effective at improving patient-oriented outcomes than existing drugs.25
When evaluating new drug studies, physicians should wait for testify that the new drug as well improves patient-oriented outcomes more than older drugs, and not just more than placebo. Physicians should be wary of the influence of the sample cupboard. Studies have shown that access to samples can influence choices independent of good clinical judgment.26,27
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REFERENCES
evidence all references
1. Pancholi Thousand, Stagnitti M. Outpatient prescribed medicines: a comparison of use and expenditures, 1987 and 2001. Statistical Cursory #33. Rockville, Md.: Bureau for Healthcare Research and Quality, June 2004. Accessed May 24, 2006, at: http://world wide web.meps.ahrq.gov/mep-sweb/data_files/publications/st33/stat33.pdf. ...
2. de Vries TP, Henning RH, Hogerzeil HV, Fresle DA. Guide to skilful prescribing. A applied transmission. World Health Organization Activeness Programme on Essential Drugs. Accessed May 24, 2006, at: http://whqlibdoc.who.int/hq/1994/WHO_DAP_94.11.pdf.
3. Commonwealth of australia Department of Wellness and Ageing. The national strategy for quality use of medicines. Apparently English ed. Canberra, Australia: Wellness and Ageing, 2002.
four. Mottur-Pilson C. Patient safety CME curriculum. Patient safety: the other side of the quality equation. Accessed May 24, 2006 at: http://www.acponline.org/ptsafety/mederrors.ppt#1.
5. National Prescribing Centre. Medicines partnership. Accessed September 6, 2006, at: http://www.npc.co.u.k./med_partnership/index.htm.
six. Wolfe SM. Worst pills, best pills: a consumer's guide to avoiding drug-induced death or illness. New York, N.Y.: Pocket Books, 2005.
7. Rose PW, Harnden A, Brueggemann AB, Perera R, Sheikh A, Cheat D, et al. Chloramphenicol treatment for acute infective conjunctivitis in children in primary intendance: a randomised double-blind placebo-controlled trial. Lancet. 2005;366:37–43.
viii. Chobanian AV, Bakris GL, Black Hr, Cushman WC, Green LA, Izzo JL Jr, et al. The 7th study of the Joint National Committee on Prevention, Detection, Evaluation, and Handling of High Blood Pressure: the JNC 7 written report [published correction appears in JAMA 2003;290:197]. JAMA. 2003;289:2560–72.
9. Picayune P, Rumsby K, Kelly J, Watson L, Moore M, Warner Thousand, et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293:3029–35.
x. Shaughnessy AF. STEPS drug updates. Am Fam Doctor. 2003;68:2342–viii.
11. U.k. Prospective Diabetes Study Grouping. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ. 1998;317:713–20.
12. National Coordinating Quango for Medication Error Reporting and Prevention. Council recommendation. Recommendations to heighten accurateness of prescription writing. Accessed May 24, 2006, at: http://www.nccmerp.org/council/council1996-09-04.html.
13. Santell JP. Confusing abbreviations can lead to drug errors. Error Watch November 2004;67. Accessed May 24, 2006, at: http://www.usp.org/pdf/EN/patientSafety/errorWatch2004-11-01.pdf.
14. Teichman PG, Caffee AE. Prescription writing to maximize patient safety. Fam Pract Manag. 2002;9:27–30.
xv. Holroyd KA. Assessment and psychological management of recurrent headache disorders J Consult Clin Psychol. 2002;70:656–77.
sixteen. Erman MK. Therapeutic options in the treatment of insomnia. J Clin Psychiatry. 2005;66:xviii–23.
17. Little P, Dorward Chiliad, Warner G, Stephens Thousand, Senior J, Moore Thousand. Importance of patient pressure and perceived pressure and perceived medical demand for investigations, referral, and prescribing in primary intendance: nested observational study. BMJ. 2004;328:444.
xviii. Haynes RB, Yao 10, Degani A, Kripalani S, Garg A, McDonald HP. Interventions to enhance medication adherence Cochrane Database Syst Rev. 2005;(4):CD000011.
19. Airplane pilot F, Standridge JB, Swagerty D. Caring for the elderly: a case-based approach. An American Family Medico monograph. Leawood, Kan.: American Academy of Family Physicians, 2005.
20. Rochon PA, Gurwitz JH. Optimising drug handling for elderly people: the prescribing cascade. BMJ. 1997;315:1096–ix.
21. Piette JD, Heisler M, Wagner Thursday. Price-related medication underuse: do patients with chronic illnesses tell their doctors?. Curvation Intern Med. 2004;164:1749–55.
22. Hash 1000. Testimony of Michael Hash, Deputy Administrator, Health Care Financing Administration on Prescription Drug Coverage for Medicare Beneficiaries before the House Commerce Committee, Subcommittee on Health and Environment [press release]. U.Due south. Department of Heath and Human being Services, Centers for Medicare and Medicaid Services; September 28, 1999. Accessed May 24, 2006, at: http://www.cms.hhs.gov/apps/media/press/testimony.asp?Counter=546.
23. Rothschild JM, Lee Thursday, Bae T, Bates DW. Clinician utilize of a palm peak drug reference guide. J Am Med Inform Assoc. 2002;9:223–ix.
24. Clauson KA, Seamon MJ, Clauson Equally, Van TB. Evaluation of drug information databases for personal digital assistants. Am J Health Syst Pharm. 2004;61:1015–24.
25. Lasser KE, Allen PD, Woolhandler SJ, Himmelstein DU, Wolfe SM, Bor DH. Timing of new black box warnings and withdrawals for prescription medications. JAMA. 2002;287:2215–20.
26. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005;118:881–4.
27. Schumock GT, Walton SM, Park HY, Nutescu EA, Blackness-burn JC, Finley JM, et al. Factors that influence prescribing decisions. Ann Pharmacother. 2004;38:557–62.
Members of diverse family unit medicine departments develop manufactures for "Clinical Pharmacology." This is one in a series coordinated by Allen F. Shaughnessy, Pharm.D., and Andrea E. Gordon, Grand.D., Tufts University Family unit Medicine Residency, Malden, Mass.
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