9.1: Repeat prescribing

The Medical Council of New Zealand Good prescribing practice outlines the requirements of prescribing and the expected conduct of prescribing doctors. 

Prescribing conduct is an activity between a patient and a doctor, any misconduct is managed by the Medical Council with possible Health and Disability Commissioner and Disciplinary Tribunal involvement.

Repeat prescribing

Repeat prescribing is a continuation of the original prescribing activity and involves administration and team member involvement. Because errors can also occur with repeat prescribing, especially as more personnel are involved, it requires a robust process with close controls.

The appropriateness of long-term repeat prescribing and repeat prescribing without a consultation is a matter of professional judgement. 

The documented policy for repeat prescribing needs to outline a reliable, safe and consistent approach to repeat prescribing.

Before signing a repeat prescription, the secure procedures should ensure:

• The patient is issued with the correct prescription
  
• Each prescription is regularly reviewed so that it is not issued for a medicine that is no longer required
  
• The correct dose is prescribed for medicines where the dose varies throughout the duration of the treatment
  
• Any subsidy conditions that have changed since the last prescription are amended
  
• All relevant information has been reviewed before completing the prescription

Repeat prescriptions should include details about the period of supply and state if more frequent dispensing is required in the interests of patient safety. Pharmacists are required to use their professional judgement to determine if more frequent dispensing is appropriate, so liaising with the patient’s pharmacist may be helpful.

Patients receiving repeat prescriptions should be assessed on a regular basis to ensure that the prescription remains appropriate. The practice’s repeat prescribing policy should include a definition of what constitutes ‘appropriate regular’ review. This will take into consideration individual patients needs and specific medications.

Patients who need a further examination or assessment should not receive repeat prescriptions without being seen by a doctor or nurse practitioner. This is particularly important in the case of medicines with potentially serious side effects.

e-Prescribing
If the practice is utilising e-Prescribing, there should be a documented process for this. In a pandemic or other event with severe disruption to services, this process may be updated to include any special provisions, or changes to prescribing regulations. 

Repeat prescribing policy 

Repeat prescribing policy and procedure should include:

• A reliable, safe, and consistent approach to repeat prescribing including roles and responsibilities
  
• Assessment guidelines on a regular basis to ensure that the prescription remains appropriate
  
• A definition of what constitutes ‘appropriate regular’ review
  
• Guidelines around some medical conditions and categories of medicines
  
• Additional measures to optimise Māori access to repeat prescriptions and collection of medicines
  
• An e-prescribing process (if applicable) 
  
• How the policy is always accessible to the clinical team
  
• Annual auditing process which include audits that differentiate Māori from non-Māori 
  
• How audits will be discussed and actioned at clinical governance meetings. 
  

NB: Your practice policies/procedures, should adhere to the general structure suggested here and include document control measures. 

9.2 Standing orders 

In general practice a standing order is a written instruction issued by a medical practitioner or NP (nurse practitioner) which authorises a specified person (usually a registered nurse) to administer or supply a particular medicine and some controlled drugs in certain situations. 

The intention is for standing orders is to improve patients’ timely access to medicines; for example, by authorising a registered nurse to administer medicines in a primary health care setting.
The issuer (GP or NP) is responsible as the prescriber. The Ministry of Health Standing Order Guidelines 2016, enable a medicine to be provided under a standing order in a way which safeguards all those involved, including the patient. 

Standing orders are very documentation heavy and time consuming, therefore, when developing standing orders it is a good idea to consider whether they are really needed.

It is essential standing orders are done correctly and in order to get it right,  practices should adhere closely to the Ministry of Health: Standing order guidelines August 2016 .

Standing orders policy

Standing orders policy and procedures should include: 

• Adherence to the current Ministry of Health guidelines for standing orders
• Who administers and works under the standing order
• Why the standing order is required including context and scope 
• A review of the competency/training annually for standing orders
• Methods of countersigning and auditing

 A standing order must include: 

• The condition being treated
• Rationale
• Practice details
• Scope
• Medicines(s)
• Route of administration
• Indication
• Precautions/exclusions
• Persons authorised
• Training requirements
• Countersigning or auditing
• Definition of terms
• Additional information (administration/supply info) 
• Issuer authorisation 

9.3 Medicines reconciliation

Medicine reconciliation is about obtaining the most accurate list possible of patient medicines, allergies and adverse drug reactions (ADRs). By using this information within the practice as well as across the health sector, it will ensure the safe and effective use of medicine. 

Communication between health professionals is key to the medicine reconciliation process and will significantly reduce medication errors caused by incomplete or insufficient documentation and will also reduce errors that could otherwise cause harm to the patient. 

The Health Quality and Safety Commission (HQSC) have produced the Medicine Reconciliation Standard which has been endorsed as the Standard for the New Zealand health and disability sector by the Health Information Standards Organisation (HISO), a committee that reports to the National Health IT Board.

The Standard applies to any person or organisation that provides medicine reconciliation within the New Zealand health and disability sector. It applies to both the paper and electronic medicine reconciliation process.

Summary of the HQSC Medicine Reconciliation Standard
1. Accountabilities and Responsibilities

• All registered healthcare practitioners involved in medicine reconciliation are responsible and accountable for the accuracy and quality of information provided to support the medicine reconciliation process at a given point in time.
• Each organisation ensures each healthcare practitioner involved in the medicine reconciliation process is able to undertake their role and responsibilities competently

2. Medicine Reconciliation Processes

• Collect: The healthcare practitioner collects the most accurate list of medicines, allergies, and adverse drug reactions (ADRs) using a minimum of two source types.
• Compare: The healthcare practitioner compares the collected medicines, allergies and ADR list against the prescribed information, such as the medication chart, identifying and documenting any discrepancies. 
  
• Communicate:  At each transfer point, all changes that have occurred to the patient’s medicines, allergies and ADR lists will be documented, dated, and communicated by the healthcare practitioners involved to ensure the care of the patient is continued.

3. Documentation

• Any information associated with medicine reconciliation is complete, accurate, relevant and current. The responsibility for this remains with the healthcare practitioners involved.
  

4. Measuring, Evaluation and Reporting

• Measuring and evaluation: Medicine reconciliation process, impact and balance measures are undertaken at regular intervals for learning and improvement using a continuous quality improvement cycle, for example, Plan – Do – Study – Act (PDSA) cycle.
• Reporting:  Each organisation ensures reporting on medicine reconciliation meets local and national requirements, for example, certification.

Systems should be in place to facilitate data collection from both patients and healthcare practitioners to measure and evaluate the success of the current medicines reconciliation process 

The PDSA cycle can: 

• identify areas where improvements can be achieved (auditing)
  
• show that improvement is being achieved
• show that improvement is being sustained

Things to evaluate and consider:

• How well are changes being implemented, for example, are timeline targets being met within 24 hours?
  
• What is the impact - are you achieving improvement and reducing discrepancies?
• Are the changes to improve this part of the system causing new problems in other parts of the system, for example, delays in patients receiving their medicines?

This process should continue at regular intervals with results and learnings contributing to ongoing team support and training. 

Relevant learnings and changes should be reported to the clinical governance group.

A medicine reconciliation policy ensures the right patients receive the right medications in the right dose at the right time. Reconciling medications reduces the risk of medication errors and confusion that may occur during patient transfer of care. 

Medicines’ Reconciliation Policy

The practice’s Medicines’ Reconciliation Policy should include:

• Purpose
  
• Accountabilities and responsibilities, both personal and organisational
  
• The medicine reconciliation process:
  
  • Timelines
    
  • Collection and accurate identification of a patient’s current list of medications
    
  • Comparing the information collected to a list of medicines recently available to the patient
    
  • Identifying and resolving discrepancies
  • Accurately recording and communicating the outcomes
• Education and training requirements:
  • Included in new team training
• Audit process:
  • Describe the audit tools the practice uses
    
  • Audit example: monitor health inequity gaps by using prescribing audits differentiating Māori from non-Māori , for example, comparing prescriptions for gout
  • Measuring and evaluation
• Processes are audited at regular intervals followed by a continuous quality improvement cycle (for example, PDSA)
  
• Reporting:
  • Relevant learnings are reported to the clinical governance group
  • Each organisation ensures reporting on medicine reconciliation meets local and national requirements

NB: Your practice policies/procedures, should adhere to the general structure suggested here and include document control measures. 

Clinical record reviews 
Practice's may wish to utilise the clinical record review self-audit checklist to ensure that clinicians are documenting and managing patient records correctly.

Patient records
Recording prescribing information electronically provides accurate, readily accessible data for continuity of patient care and an audit trail of activity.

Clear and accurate patient records contain all relevant clinical findings, decisions made, information given to the patient, and the medicines and any other treatment prescribed.

The patient record should include adequate patient medication history, including:

• Current medical conditions
  
• Any previous adverse reactions
  
• Concurrent or recent use of medicines (including non-prescription, complementary and alternative medicines)