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Section 2 – Special Prescribing Circumstances

Practice Guidance 18: Family, friends and close colleagues

18.1 You should wherever possible avoid prescribing for those close to you. People close to you may include your immediate family (parents, grandparents, children, grandchildren, siblings, aunts, uncles and first cousins), someone with whom you have an intimate personal relationship, your friends, and may also include colleagues with whom you regularly work. People you prescribe for should be formally on your caseload as your patient and can only be done under a CMP.

18.2 You must be able to justify your decisions to prescribe for those close to you. You must record the nature of your relationship and the special circumstances that necessitated your action of prescribing for family and friends.

Practice Guidance 19: Prescribing for Children

19.1 Supplementary prescribers can prescribe for children within a CMP but it is essential that radiographers recognise the unique implications for children and young people. Caution should also be taken when prescribing for pregnant and lactating women.

19.2 Only radiographers with relevant education, training and competence in treating children should prescribe for children and can demonstrate that children are within their area of expertise and level of competence.

19.3 In all cases reference should be made to the following documents that address medicines management issues in paediatrics:

  •   The BNF for Children (England/Wales/Scotland) at www.bnfc.org
  • Medicines Standard: National Service Framework for Children, Young People and Maternity Services at www.dh.gov.uk under Policy and Guidance, Health and Social Care Topics, Children Services
  •  Medicines Standard: National Service Framework for Children, Young People and Maternity Services (Wales)
  • Royal College of Paediatrics and Child Health – information on use of licensed and unlicensed medicines at www.rcpch.ac.uk/publications
  • Scottish Executive - The Administration of Medicines in Schools and The Right Medicine: A Strategy for Pharmaceutical Care in Scotland
  • SIGN Guidance at www.sign.ac.uk
  •  DHSSPS – Medicines Management Standard
  • DH – Every Child Matters (2004)

Practice Guidance 20: Prescribing Unlicensed Medicines

20.1 Medicines may be classed as unlicensed either as original products, or by virtue of their preparation e.g. mixing two licensed medicines together which creates a new unlicensed product. An unlicensed medicine does not hold a UK Marketing Authorisation issued by the MHRA.

20.2 A Supplementary Prescriber may prescribe unlicensed medicines within a written CMP, but if you decide to do so you must:

  • Be satisfied that an alternative, licensed product would not meet the patient’s needs
  • Be satisfied that there is a sufficient evidence base of using the unlicensed medicine to demonstrate safety and efficacy
  •  Record the medicine prescribed and the reasons for using an unlicensed product in the patients notes
  • You must clearly explain to a patient if you will be prescribing unlicensed medicines or using a medicine in a way not specified within the Summary of Product Characteristics. The patient has the right to refuse to accept any medication you may prescribe for them, but if they do so you should explain the risks, benefits and outcomes of their decision

Practice Guidance 21: Off label use of medicines

21.1 An off-label medicine does hold a UK Marketing Authorisation issued by the MHRA, but is being used in a way that is not described within the medicine’s Summary of Product Characteristics.

21.2 Supplementary Prescribers may prescribe medicines for off-label use, but if you decide to do so you must:

  •  Be satisfied that a licensed medicine is not available which includes your proposed usage within its SPC
  • Be satisfied that there is a sufficient evidence base for using the medicine in an off-label way to demonstrate safety and efficacy. Where the manufacturer’s information is of limited help, the necessary information should be sought from another reliable and reputable source
  • Record the medicine prescribed and the reasons for using an off-label product in the patients notes
  • You should explain to a patient in broad terms why you are using the medicine in an off-label way
  • You should make a clear, accurate and legible record of your reasons for using a medicine in an off-label manner

21.3 Pharmaceutical companies do not usually test their medicines on children and consequently cannot apply their Marketing Authorisations for their products to use in children. It is often necessary in paediatric practice to use licensed medicines in off-label ways. You must consult the BNF for Children before prescribing for children.

Practice Guidance 22: Remote prescribing

22.1 Most prescribing should occur on the basis of a face-to-face consultation with the patient. Remote prescribing occurs if you issue a prescription based on a telephone, e-mail, fax, video-link, web-based or other non face-to-face contact with a patient.

22.2 You should only remote-prescribe for your own patients or patients on your own case-load. You must ensure that you have an appropriate dialogue with your patient to:

  • Establish the patient’s current medication history
  • Carry out an adequate assessment of the patient’s condition
  • Ensure there is sufficient justification to prescribe the medicines remotely, including discussing the feasibility of seeing another prescriber who can carry out a face-to-face consultation. This is particularly important when a remote-consultation does not permit an adequate assessment of the patient’s condition to be undertaken
  • Ensure there are no contraindications to the proposed medicine
  • Ensure arrangements are in place to provide follow-up and continuity of care
  • Ensure a clear record is made of the prescribing decision and in particular the method of remote prescribing used e.g. instruction over the phone, e-mail etc
  • Ensure that the primary care record holder is informed
  • Ensure that the patient has ‘sufficient information’ to make an informed choice to accept your recommendation

22.3 Where you cannot satisfy all of the conditions above, you should not use remote means to prescribe for your patient.

22.4 Where a medication has not been prescribed before, you should not prescribe remotely if you have not assessed the patient, except in life-threatening situations.

Practice Guidance 23: Use of patients own medicinal products

23.1 Patients may have their own supply of medicines that they seek your advice on. These medicines may:

  • Have been prescribed by another prescriber,
  • Have been bought over the counter
  • Be herbal or homeopathic preparations that may , or may not, be subject to MHRA registration
  • Be complementary products

23.2 Such products are the patient’s own property and must not be removed without the patient’s permission.

23.3 You may ask to see such products, or the patient may ask you about their suitability for continued use. Provided you are educated, trained and competent to do so you may:

  • Check that the products are suitable for the patient to use and if they are not you should advise the patient of this
  • Explain how the medicine should be taken, including explaining any direction given by another prescriber in the case of prescribed medicines. If the patient is not taking the medicine as directed, you should advise of any changes needed to achieve this
  • Give advice on dose alteration, including stopping medication. If this relates to a POM product prescribed by another professional you must have access to the primary medical record in order to record the change you have made to a prescribed medicine.
  • Advise a patient that a given product may not be suitable for the patient’s needs or may cause an interaction with other products that may cause unexpected effects for the patient

Practice Guidance 24: Controlled drugs

24.1 Controlled drugs may be prescribed by a Supplementary prescriber working within a written Clinical Management Plan (CMP). Further changes to Home Office Regulations will be required to permit physiotherapist Independent Prescribers to prescribe controlled drugs from a limited list.

24.2 Radiographers are most likely to use controlled drugs in settings and circumstances where patients are cared for as part of a medical Consultant-led team and where the radiographer has regular and on-going access to the Consultant. Examples include A&E and in-patient hospital settings for management of acute and pre/post-operative pain, palliative care and end-of-life care; out-patient hospital settings for chronic pain management; hospice care for palliative and end-of-life care

24.3 An example FP10 prescription for controlled drugs is included within the BNF. You must ensure you have the most current version of the controlled drugs prescription form.

24.4 The legal requirements for prescribing Schedule 2 and 3 controlled drugs are summarised in the BNF. You should also ensure the recommendations from the 4th Report of the Shipman Inquiry are followed:

  • Prescriptions for controlled drugs are uniquely marked to identify them as controlled drug prescriptions
  • Private prescription forms for controlled drugs are similar to NHS controlled drug prescription forms
  • The registration number of the prescriber must be included on controlled drug prescriptions
  • The patient’s NHS number, or other unique identifier, will be included on the controlled drug prescription form
  • All controlled drug prescriptions, except Schedule 5, will be valid for 28 days only.

24.5 Standard Operating Procedures should be in place for the use of Controlled Drugs (CDs) and should include procedures for:

  • Ordering and receipt of CDs
  • Assigning responsibilities
  • Where the CDs are to be stored
  • Who has access to CDs
  • Security in the storage and transportation of CDs as required by Misuse of Drugs legislation
  • Disposal and destruction of CDs
  • Who is to be alerted if complications arise
    • Record keeping, including:
    • Maintaining relevant CD registers under Misuse of Drugs legislation
    • Maintaining a record of the CDs specified in Schedule 2 to the Misuse of Drugs Regulations 2001 that have been returned by patients

The Standard Operating procedures should also include:

  • Responsibilities within the multidisciplinary team
  • Validation by the healthcare organisation and date
  • Review period, e.g. one, two or three years
  • Lead author and named people contributing to the Standard Operating Procedure

Practice Guidance 25: Mixing

25.1 Under the terms of the Medicines Act, when two medicinal products are mixed together prior to administration and one cannot be described as the vehicle for the other, this meets the definition of ‘manufacture’ and results in a new unlicensed product. Combinations of licensed medicines may be used in a wide range of clinical settings, but in each case where two medicinal products are mixed and one cannot be described as a vehicle for the other, there are restrictions on the use of ’mixed medicines’. The act of ‘mixing’ is not in itself prescribing.

25.2 Mixing of medicines is only permissible within the terms of a supplementary prescribing CMP or as part of a PSD.

25.3 Mixing CANNOT occur as part of a PGD.

25.4 Please refer to the National Prescribing Centre guidance on the mixing of medicines, which can be accessed at: http://www.npc.co.uk/

Practice Guidance 26: Prescribing on the recommendation and/or the request of others

26.1 You should only prescribe for patients on your own caseload/under your overall care and under a CMP. You cannot prescribe for any patients upon whom you have not undertaken an appropriate assessment. You must not prescribe for a patient unknown to you simply because you are the only prescriber available except in an absolute emergency where the patient’s life is in imminent danger.

26.2 The requirements for non-medical independent prescribing are not the same as for medical prescribing. If you prescribe on the recommendation of another health professional who does not have prescribing rights, you must satisfy yourself that you have performed an appropriate assessment of the patient yourself in order to reach a diagnosis in order to determine if the prescription request is appropriate for the patient concerned and that the professional is competent to have recommended the medication.

26.3 You do not necessarily have to conduct a face-to-face consultation with the patient but you must ensure an appropriate assessment has taken place in order to gain enough sufficient information upon which to make your prescribing decision. Where you cannot satisfy yourself of this, you should not prescribe on the recommendation of others.

Practice Guidance 27: Simultaneous prescribing and administration

27.1 Prescribing and/or supply followed by simultaneous administration of medicine to the patient creates the opportunity for errors to occur as there is no formal division between the prescribing and then supply and/or administration functions.

27.2 If you prescribe for a patient you should allow someone else, ideally a Pharmacist, to supply the medicine to the patient wherever possible prior to administration.

27.3 Where prescribing and/or supply occurs simultaneously with administration of medicine to the patient this should only be done where it is in the patient’s best interests for this to occur AND there should also be an additional check by a second person to ensure that what is prescribed is actually what is supplied and/or administered to the patient. The second ‘checker’ need not be a prescriber or registered health-professional themselves but should be able to verify that the correct medicine is being supplied to the patient.

27.4 All radiographers using a PGD to supply and administer medicines should consider the need to have a ‘second checker’ to ensure that the patient receives the correct medicine.

 

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