Ten Principles of Good Prescribing – J K Aronson

 

The Hitchhiker’s Guide to Clinical Pharmacology Part 3: Choose wisely, inform, start low, and monitor

Jeffrey K Aronson

 

In a podcast interview with Carl Heneghan on the subject of clinical pharmacology, I mentioned the British Pharmacological Society’s Ten Principles of Good Prescribing.

Prescribing medicines is the main approach to the treatment and prevention of disease and the alleviation of symptoms in modern healthcare. While medicines have the capacity to enhance health, all have the potential to cause harm if used inappropriately (see Box 1).

Box 1. Harms from medicines in the UK

Numbers of patients affected by adverse drug reactions

  • Accident & emergency visits, 2.5%
  • Hospital admissions, 6.5%
  • Inpatients, 15%
  • Primary care visits, 25%

Reported rates of medication errors

  • Prescribing error rate in hospitals, 7% of prescription items
  • Prescribing errors rate in general practice, 5% of prescriptions of which 0.18% were severe errors; this implies 1.8 million serious prescribing errors each year;
  • Dispensing error rate in hospitals, 0.02–2.7% of dispensed medicines
  • Dispensing error rates in community pharmacies, 0.01–3.32% dispensed medicines
  • Medicine administration errors in hospital, 3–8%

 

For these reasons, the British Pharmacological Society recommends that healthcare professionals who prescribe medicines should do so based on ten principles that underpin the safe and effective use of medicines. They are summarized in Box 2, with notes below.

 

Box 2. Ten principles of good prescribing

All prescribers should:

  1. Be clear about the reasons for prescribing
  2. Take into account the patient’s medication history before prescribing
  3. Take into account other factors that might alter the benefits and harms of treatment
  4. Take into account the patient’s ideas, concerns, and expectations
  5. Select effective, safe, and cost-effective medicines individualized for the patient
  6. Adhere to national guidelines and local formularies where appropriate
  7. Write unambiguous legal prescriptions using the correct documentation
  8. Monitor the outcomes of treatment, both beneficial and adverse
  9. Communicate and document prescribing decisions and the reasons for them
  10. Prescribe within the limitations of your knowledge, skills, and experience

 

In case this is too much to take in at one go, I recommend the following mantra, which summarizes the important points:

Choose wisely, inform, start low, and monitor.

 

Notes on the ten principles of good prescribing

 

  1. Be clear about the reasons for prescribing
  1. Take into account the patient’s medication history before prescribing
  1. Take into account other factors that might alter the benefits and harms of treatment
  1. Take into account the patient’s ideas, concerns, and expectations
  1. Select effective, safe, and cost-effective medicines individualized for the patient
  1. Adhere to national guidelines and local formularies where appropriate
  1. Write unambiguous legal prescriptions using the correct documentation
  1. Monitor the outcomes of treatment, both beneficial and adverse
  1. Communicate and document prescribing decisions and the reasons for them
  1. Prescribe within the limitations of your knowledge, skills, and experience

 

Box 3. Licensed medicines, unlicensed medicines, and off-label prescribing in the UK

Licensed medicines

The UK regulatory authority grants product licenses (known formally as Marketing Authorisations), permitting license holders to market medicinal products for specified indications under specified conditions. Such products are licensed medicines.

The label

Every license for a medicinal product contains information about the approved uses of the product; this information is known as the label and is given in the Summary of Product Characteristics (SmPC), whose contents are regulated by law. The information includes the pharmaceutical form, the therapeutic indications, doses, and mode of administration, contraindications, special warnings and precautions for use, adverse drug effects and reactions, and drug interactions.

Off-label prescribing

If a licensed medicine is prescribed in a way that differs from the descriptions listed in the SmPC, that is off-label prescribing. For example, if bevacizumab, which is licensed for the management of various cancers, is used to treat age-related macular degeneration, that is off-label prescribing. This is not the same as prescribing an unlicensed medicine.

Unlicensed medicines

An unlicensed medicine is one that does not have a license in the UK.

MHRA advice on priorities when prescribing

(a)  use a licensed product within the terms of its license (i.e. the label);

(b)  use a licensed product off-label;

(c)  use an imported product that has a license elsewhere;

(d)  use a product that is not licensed anywhere, but which has been manufactured in the UK as a “special”.