PMAR (PRESCRIPTION MEDICINE ADMINISTRATION RECORD) ENDORSEMENT BY PHARMACY STAFF CLINICAL GUIDELINE Register no: 10092 Status - Public Developed in response to: Local need Contributes to CQC 12 Consulted With Post/Committee/Group Date Senior Pharmacy Management Team May 2016 Professionally Approved By Jane Giles, Chief Pharmacist June 2016 Version Number 5.0 Issuing Directorate Pharmacy Ratified by: DRAG Chairmans Action Ratified on: 10 th June 2016 Executive Management Board June 2016 Sign Off Date Implementation Date 14 June 2016 Next Review Date May 2019 Author/Contact for Information Maria Richards Policy to be followed by All pharmacy staff Distribution Method Hard copy to be kept in dispensary Electronic copy on pharmacy shared drive Copy to be e-mailed to all pharmacy staff Intranet & website Related Trust Policies (to be read in conjunction with) Management of Medicines Policy, Guidelines for the Management of Medication errors, Investigating & Learning from Incidents Policy, Near Misses and Adverse Drug Reactions, Administration of IV Medication and Administration of Chemotherapy Agents, Policy for Non-medical Prescribers, Risk Management Policy Document Review History Version No Authored/Reviewed by Active Date 1.0 22nd July 2010 1.1 3rd May 2011 2.0 27th October 2011 2.1 Amendment to Monitoring Section May 2012 3.0 Review Maria Richards February 2013 4.0 Review Maria Richards 23rd May 2014 4.1 Amendment to Dose Units Section Maria Richards September 2014 5.0 Maria Richards 14 June 2016 1
Index 1. Purpose 2. Scope 3. Training 4. Descriptions 5. Patient and ward details 6. Drug sensitivity box 7. Drug name 8. Dose units 9. Paediatric prescriptions 10. Route of administration 11. Devices 12. Clinical accuracy check 13. Pharmacy endorsement of supply of stock 14. Instructions for administration 15. Drug interactions 16. Specific examples 17. Transcription checks 18. Inpatient IV information 19. Medicines reconciliation on admission 20. Monitoring 21. Communication 22. References 2
1. Purpose 1.1 To ensure Pharmacy staff endorse prescriptions to a high standard and in a clear and consistent manner so that all healthcare professionals are able to understand the information being documented and which medicines have been supplied. 2. Scope 2.1 All pharmacy staff including Pharmacists, Technicians and ATOs in the dispensary and wards service. 3. Training 3.1 Training is delivered in accordance with the training needs analysis (Learning & Development strategy). 3.2 All staff endorsing PMARs (Prescription Medicine Administration Record) charts must have read and understood this policy. 4. Descriptions 4.1 The following guidelines are an aid to endorsing PMARs by pharmacy staff to ensure consistency. Pharmacy staff should use these guidelines appropriately. For example, do not endorse a chart with or after food if a patient is nil by mouth. The guidelines are not exhaustive. 4.2 Drug Prescription and Administration record include the following: Inpatient chart infusion and IV therapy chart Outpatient prescription chart Anticoagulant chart Chemotherapy outpatient chart Insulin sliding scale chart 4.3 In all cases, any addition or amendment made to a PMAR by any member of pharmacy staff must be written in green pen in order to identify it as a pharmacy intervention or medicine supply. No other colour pen is acceptable for use in this way. 5. Patient and Ward Details 5.1 Ensure that every chart is marked with the patient s name, weight (essential if a child), hospital number, ward or department and consultant. 5.2 Where there is more than one chart for the patient write 1of 2 charts and 2 of 2 charts etc. 6 Drug Sensitivity Box 6.1 The drug sensitivity box on the PMAR should be completed for all patients except babies in the Neonatal Intensive Care Unit (NICU) and maternity wards. In the event of a neonate in NICU/maternity wards exhibiting an adverse reaction to a particular drug, the drug sensitivity box must be completed immediately. 3
6.2 If checking the chart on the ward and the drug sensitivity box is not completed: The pharmacist should check relevant sources, including the medical notes, previous drug charts, alert label etc. If the patient has a documented drug allergy, the pharmacist may either: o contact the doctor verbally or in writing, stating the relevant drug(s) or o complete the allergy box All entries in the allergy box must be signed and dated by the person completing the box If the patient has no documented drug allergy then nil known or NKDA should be endorsed in the allergy box NOTE: The prescriber (usually the doctor) still has the primary responsibility for ensuring that the allergy/sensitivity details are completed on all relevant drug charts and pharmacy staff and nursing staff should encourage this. If the patient is receiving a drug to which he/she has a documented drug allergy, the pharmacist should inform the doctor responsible for the care of the patient at that time. If the documented allergy was incorrect, this should be amended in the medical record and in the drug sensitivity box. 6.3 If checking the chart off the ward and the drug sensitivity box is not completed the pharmacist should use their professional judgement: Endorse the words please complete in the allergy box Discuss with the prescriber and ward staff, and then endorse as appropriate. 7. Drug Name Any endorsement to a drug name should be made in block capital letters in the drug name box whenever possible. 7.1 Legibility If the drug name is not clearly legible, endorse the chart with the generic drug name. 7.2 Generic name If the drug is prescribed by its brand name, endorse the approved generic drug name. 7.3 Brand name For certain drugs, ensure that the brand name appears on the chart. This applies to the following drugs: Diltiazem (except when prescribed TDS) 4
Theophylline S/R preparations Ciclosporin Nifedipine S/R preparations Lithium Carbamazepine (M/R) Insulins Tacrolimus Semisodium valproate 7.4 Abbreviations 7.5 Form Ideally write out the drug name in full e.g. : ISMN must be endorsed as isosorbide mononitrate FeSO 4 must be endorsed as ferrous sulphate Ensure the form of the preparation is appropriately endorsed, including with SR or MR for sustained release preparations and EC if needed e.g. sodium valproate tablets need endorsement of SR or EC to clarify preparation required. 8. Dose Units 8.1 Where the number of dose units is prescribed, and the drug is available in more than one strength, endorse the chart with the appropriate drug strength (after clarifying the information using an appropriate source). For example: Beclomethasone inhaler II puffs BD One puff = 100 microgram Amlodipine tablets 1 OM 1 = 5mg 8.2 Where the formulation is a liquid, clarify the dose prescribed as strength and volume, considering the preparation supplied. For example: Folic acid 400mcg 400 microgram = 0.8ml of folic acid 2.5mg in 5ml liquid 8.3 The following abbreviations should be written in full: U or IU = units mcg = microgram 8.4 Remove any unnecessary zeros. For example: 5.0mg = 5mg 0.5mg = 500micrograms 9. Paediatric prescriptions 9.1 All paediatric prescriptions should be endorsed with the strength of preparation and volume to be given in addition to the dose prescribed (except where tablets are being given). For example: 5
Domperidone 1mg/ml 1.5mg tds (1.5ml tds) 10 Route of administration 10.1 If the dosage varies according to the route of administration, the pharmacist may add the dosage for the different routes e.g. Prochlorperazine PO/IM Oral = 5 10mg, IM = 12.5mg It may also be necessary to ask nursing staff to confirm which route of administration was used, by writing this in the additional instructions box. 11. Devices 11.1 If the drug is available through different devices, endorse the chart appropriately. Insulins - endorse the chart with vial, disposable pen, cartridge + cartridge size Inhalers - endorse the chart with the inhaler type, such as turbohaler, accuhaler, diskhaler, etc Spacers - endorse the chart if the patient uses an inhaler with a spacer device, such as volumatic or aerochamber Compliance aids - endorse the chart if the patient uses a compliance aid such as a medidose container, haleraid etc Where a medidose/blister pack is used, record this in the grey drug history box of the chart along with the name and phone number of the Pharmacy where possible. 12 Clinical accuracy check 12.1 When the pharmacist is content that the prescription is correct, the pharmacist should initial the prescription in the pharmacy screen box. 12.2 When a chart is sent down to pharmacy for supply of medications, the screening pharmacist should sign all prescriptions on the chart once they are content with its accuracy and not just the items to supply. The dispensary screen box may be signed and dated on the front of the chart. 13 Pharmacy endorsement of supply or stock 13.1 These annotations should be made in the pharmacy supply box or in the additional instruction box if there is no room in the pharmacy supply box. Stock drugs TTA supply Endorse the chart S or stock and the ward e.g. SB23 or STOCK B23 Endorse the chart with the quantity supplied and the date e.g. [28] 3/10 6
Stock check Patient s Own Meds Endorse the chart with the quantity of drug remaining and the date of the stock check e.g. 5 left 5/4 Endorse the chart POD, quantity remaining and date of check. e.g. 5 POD 5/4 If the patient has a supply at home, the chart may be endorsed with PODH Inpatient supply (no directions) Endorse the chart IP with the quantity of drug supplied e.g. 5 IP 5/4 Where these endorsements are being made in the dispensary (i.e. when charts have been sent to pharmacy for supply), they should be signed by the dispenser and the checker. 14 Instructions for Administration 14.1 Endorse appropriate administration instructions in the Other instructions box e.g. Oral Administration: With or after food Swallow without chewing Take with plenty of water Chew before swallowing 14.2 For administration via an NG tube, PEG tube, NJ tube etc: Crush and disperse tablets in water (or other appropriate directions) 14.3 For patches, endorse the necessity to rotate the site of application e.g. for buprenorphine weekly patches, endorse as new patch should not be applied to the same area of skin for 3-4 weeks 15. Drug Interactions 15.1 Potentially serious, clinically significant drug interactions should be endorsed in the additional instructions box or in the drug administration section ensuring it does not impede nursing staff signatures e.g. May raise theophylline levels May affect INR 15.2 When making these endorsements, consideration should be given to the possibility of the patient and/or relatives reading them. Wording should be chosen carefully. 16. Specific Examples 16.1 Endorse the following drugs with the wording shown: Alendronate swallow whole with a full glass of water 30 minutes before breakfast and then remain upright for at least 30 mins 7
Finasteride - not to be handled by women of child-bearing age unless wearing protective gloves Fybogel - take each sachet in 200ml of cold water Lactulose not effective PRN. For best effect, take regularly if required for constipation (if prescribed PRN) 17. Transcription checks 17.1 When a chart has been rewritten, where possible, this will be checked against the old chart for transcription accuracy. Once checked and complete, the chart should be signed on the front in the checked by box. 17.2 The latest supply of medications endorsed on the old chart should be transcribed to the new chart. 17.3 Any discrepancies in the grey box should be copied over to the grey box on the new chart so that outstanding issues can be followed up and/or any changes made to medications during hospital stay can be easily identified. 18. Important IV information. 18.1 Drugs to be given via the intravenous or intramuscular route should be endorsed with administration instructions e.g. DRUG Amphotericin Digoxin Erythromycin Furosemide Gentamicin (once daily dosing) Phenytoin Phytomenadione (Konakion MM) Ranitidine ENDORSING Infuse over 2-4 hours. Infuse over 2 hours. Infuse over 30-60 minutes. Inject or infuse at max rate of 4mg/ml. Infuse over 30 60 minutes. Maximum rate 50mg per minute IV bolus over 2-3 minutes. Inject over > 2 minutes. 19. Dose ranges 19.1 Where a dose range has been prescribed, this must be clarified if possible. In some cases a dose range may be appropriate (e.g. for insulin or analgesia). If this is the case, pharmacy staff will endorse in the Other instructions section, please record dose given. 8
20. Medicines Reconciliation on admission Please refer to Medicines Reconciliation Policy for further details. 20.1 All new patients should have their medicines reconciled within 24 hours of admission or, ideally, within 48 hours. However, it is recognised that this may not be possible when staffing is limited and for those patients admitted over a weekend. 20.2. When medicines reconciliation (MR) has been carried out, the grey box on the drug chart should be completed appropriately. 20.3 Any medications prescribed on the chart that the patient usually takes, should be endorsed on the left hand side with the letters OA (on admission) 20.4. For clarification, endorse any newly started medication on admission as NEW 20.5. Where dose changes have been made, make it clear that these have been taken into account by endorsing appropriately with OA or OA 20.6. The drug history should be added to ExtraMed Beds once it has been confirmed. 21. Monitoring 21.1 The pharmacy department has a responsibility for monitoring the endorsing of medicines charts. This will be done on a continuous basis whenever a chart is seen. Additional endorsements will be made when appropriate. 22 Communication 22.1. The policy will initially be communicated to all pharmacy staff involved in dispensary or ward work by e-mail and key points will be raised at the first appropriate staff meeting. Thereafter, all new staff will be shown the policy at induction. 22.2 Key points from this policy will be addressed to the nursing staff at the mandatory Medicines Management training delivered by the pharmacy department to improve understanding of pharmacy endorsements at ward level. An e-mail will be sent to ward sisters to ensure that any staff who have already attended such training will also be informed. 23 References 23.1 Procedure for endorsement of medicine record charts by pharmacists and technicians. Essex Rivers Healthcare NHS Trust. Version 2. 21.4.08 23.2 Guide to prescription chart endorsement by pharmacy staff. Addenbrooke s NHS Trust. 1st August 06. 9