All prescriptions aren’t created equal, writes Angelo Pricolo
What makes a good prescription? Ask the doctor and they’ll likely say it should relay the correct drug, dose and directions, in accordance with the consultation. Ask the Department of Health or Medicare and it’s probably more about the legal aspects of the document.
Hopefully a good prescription is a combination of both and contains the elements required to fulfill the best outcome for the patient. The prescription will take into account many factors but ultimately should document concise directions in a legal format.
Some things are a given: the patient’s name needs to be on the prescription. It is surprising however, how often names are spelled incorrectly or the wrong name appears.
Thankfully computers are reducing the incidence of illegible scripts (printers permitting) but alarmingly they are increasing the incidence of the wrong person’s name appearing on the script.
As easily as a distraction can cause a pharmacist to choose the wrong file when dispensing a drug, a doctor can also choose a relative or even still be in the last patient’s file before entering drug details.
The consequences of this can be anything from an inconvenience through to a major error in a medication history that eventually may lead to misadventure.
Legal requirements such as the date and address must appear but other personal information like date of birth can also be a useful identification tool. This is particularly useful for children’s prescriptions.
Prescriptions need to be signed. Some signatures are idle squiggles that could be forged easily. However others are identifiable and strong indicators of validity for a dispensing pharmacist. The latter also acts as a deterrent to a would-be forger and can save a phone call to confirm authenticity.
If a prescription was a bank cheque I am sure the bank would scrutinise the document more vigorously and have a higher standard than we accept. The signature really should have much more importance placed on it and doctors should be more careful and understanding of this.
It is also very helpful when uncommon doses or visible changes to dose or quantity is initialed by the doctor. This provides some comfort to the pharmacist that the doctor’s intentions are clear and the script has not been altered.
Of course it does not ensure phone contact is not necessary but it may reduce the likelihood of wasting the doctor and pharmacist’s time and taking them away from what is really important: the patient.
Sometimes legal requirements can be confused with those of the PBS. A PBS valid script requires exact quantities to be written, not just an indication of one month or one week’s supply.
It also requires dose form to be specified. For example tablets or capsules or even cream or ointment must be stated. Pharmacists risk rejection of the script and no payment if an audit reveals such oversights.
Prescriptions specifically for pharmacotherapies for the treatment of opioid dependence or Opioid Replacement Therapy (ORT) have a few special requirements. Guidelines usually referred to here and are very important but upon discussion with pharmacist can be varied.
Having said this, if that discussion does not occur beforehand then it will usually result in a phone call.
The ORT script must include the name of the dispensing pharmacy. It would be useful to also mention the name of the previous pharmacy if it’s a transfer so that checks can be made if needed.
Prescriptions must also include an expiry date. The best way to document this is to write the exact date rather than 1/12 or 6/52 as this will occasionally fall on a Sunday or public holiday with inconvenient implications for all. The exact date also eliminates the need for arithmetic and primary school rhymes (30 days has…) that surprisingly can produce variable results.
Why is it so important to not have these grey areas? The answer is that prescriptions are a legal document and must be accurate. Grey areas can also cause concern and anxiety for patients as well as create conflict with the pharmacist or doctor.
To this point removing instructions open to different interpretation is important in producing a good workable script.
So where does that leave a Suboxone® script for 12mg that allows two takeaway doses per week and a provision for double and triple doses and extra takeaways on Sundays and public holidays for an unstable patient? That’s a bad script because too much can be interpreted differently by various people and this often causes conflict.
To simplify this situation either multiple doses or takeaway doses should be used, but not both. Although the flexibility of double and triple doses cannot be denied, the outcomes seem much better with daily dosing anyway.
The other minefield is fixed dosing days. For example: Monday, Wednesday and triple dose Friday. Inevitably patients will miss Monday and turn up on Tuesday.
The best way to avoid this situation is to have a flexible prescription that allows the patient to choose their dosing days. Less wasted time for all involved. And phone calls… less phone calls.
Indicating a dose range can be good prescribing. Compared to fixed changes it has the advantage of allowing the pharmacist in consultation with the patient, the opportunity to exercise some professional judgment and tailor the appropriate dose.
As an example a script that specifies a dose +/- 5mg can offer flexibility and avoid unnecessary extra consultations.
Whereas reduce by 5mg per week leaves no room for the patient to change their mind about the new dose or return to the original dose without another doctors appointment. Often patients live with the discomfort until the next scheduled appointment.
The pharmacist often has contact with patients every day especially if they are on a substitution program or on a staged supply regimen.
Staged supply situations often need good concise instructions. So in some situations contacting the pharmacy before making changes, for example increasing takeaway doses, can be a useful practice that produces good workable prescriptions.
A good prescription takes into account information that is available, and pharmacy is an underutilised resource.
A good prescription is a considered document. Its purpose goes beyond delivering the correct drug and dose. It has a major impact on the success of a patient’s treatment.
Angelo Pricolo is a National Councillor with The Pharmacy Guild of Australia and a member of the PSA Harm Minimisation Committee.