Prescription Writing

& Drug Interaction

As to diseases, make a habit of two things --

to help or at least do no harm
Hippocrates
Book I Of Epidemics
 Classification of Drugs
• Prescription drug
– drug that requires a prescription because it is
considered potentially harmful if not used under
the supervision of a licensed health care
practitioner
• Controlled or scheduled drug
– a prescription drug whose use and distribution is
tightly controlled because of its abuse potential or
risk
– Prescriptions for controlled substances have
additional requirements by law
The laws that govern the use of medicinal
products in the UK

• The Medicines Act 1968

• The Misuse of Drugs Act 1971
• NHS Regulations

The Medicines Act, Misuse of Drugs Act and the NHS

Regulations are part of the criminal law
 The Medicines Act

Controls the production and supply of medicinal

products

• The main purpose of the Medicine Act is to protect

the public from harm
• That is; to ensure, as for as possible, that medicinal
products are safe, and they are efficacious
ie effective when compared to placebo.
 The Medicines Act
Categorisation of medicinal products
The legal ability to supply medicines is based on the
categorisation of medicinal products

There are three categories

• General Sale list medicines GSL
Nicorette 2mg chewing gum x 15 GSL
• Pharmacy medicines P
Aspirin 75mg x 100 P
• Prescription only medicines POM
Hydrocortisone Cream 0.5% POM !
 Controlled drugs
Misuse of drugs Act 1971 (and consolidated 2001)
Schedule 1 Controlled drugs which may not be used for medicinal purposes (e.g. cannabis, LSD etc)
Schedule 2 Controlled drugs including opiates (morphine, diamorphine) and major stimulants such as
amphetamines
Schedule 3 Barbiturates (except quinalbarbitone), and minor stimulant drugs
Schedule 4 Benzodiazepines, anabolic and androgenic steroids, and some other related hormones.
Schedule 5 Controlled drugs where there is a lower risk of abuse than other schedules. It includes
certain preparations containing codeine, dihydrocodeine, pholcodeine, cocaine, morphine,
dextropropoxyphene, and diphenoxylate. Common medicines in this schedule include co-proxamol, co-
codaprin, co-codamol, co-dydramol, and Oramorph solution 10mg/5ml. The classification may
depend on the strength of the controlled substance in the preparation.
 Writing Prescriptions
Who can write a Rx?
• Practitioners
– Physicians, dentists,

– nurse practitioners,
physician assistants,
optometrists,
pharmacists
 Definitions of Prescription
• A written direction for
the preparation and
administration of a
remedy
• A summary of the
diagnosis, prognosis,
and treatment plan for
a patient’s illness
• A legal document
 Format

Sample of Generic Hospital Sample of Physician Specific

Prescription Prescription
 Five Parts of Prescription
1. Superscription
- Patient’s name, age and address
- Date: Required for all prescriptions
1. Inscription- Main body
– Contains the name and strength of each
medication
– Avoid abbreviations and indicate amounts in
metric units
3. Subscription- How much drug to dispense,
refills
 Five Parts (cont.)
4.Signa (Sig.)- How to take medication, route,
frequency, indication

5.Signature- Doctor’s signature

Professional degree
DEA #, if for controlled drug
 Superscription

Lotta Celiva 65 years

Adult
You decide (pharmacist often fills this out for you)
11/5/01
 Inscription

Lotta Celiva
Adult
You decide (pharmacist often fills this out for you)
11/5/01
Atropine sulfate 0.4 mg
 Name of Drug
Spot the difference?

Look alike drugs contribute to medication errors

 Name of Drug
DEA # BC1276899
Rex Reiter, M.D.
136 Wright Way
Boston, MA 02111
1-587-822-5536 It is important to note that
(1-JUST CALL ME)

Name Mr. Slim Foote

terbinafine’s trade name is
Address 2001 Pathway Road, Lane, MA 20101 Date 2/02/02 Lamisil. There have been
 (please print)
numerous incorrectly filled
Terbinafine prescriptions in which
Lamictal, an anticonvulsant,
was dispensed instead of the
antifungal agent, Lamisil,
M.D.
when its trade name was
LABEL used.
REFILL TIMES PRN NR
INTERCHANGE MANDATED UNLESS
THE PRACTICIONER WRITES THE WORDS
‘NO SUBSTITUTION’ IN THIS SPACE
 Commonly Used and Commonly Confused
(some examples, including some name-changing solutions)

Norvasc/Navane Fosamax/Flomax
Prilosec/Prozac Lasix/Losec (now Prilosec)
Lamisil/Lamictal Chlorpromazine/Chlorpropamide
Ketoprofen/Ketotifen Epogen/EpiPen
Vioxx/Zyvox Xeloda/Xenical
Celebrex/Celexa and Cerebyx
Amiodarone/Amrinone (now Inamrinone)

Confusing these names can cause difficulties on both

prescriptions and hospital order sheets. For interested parties,
a good place to look for “look-alike/sound-alike” drugs is the
web site <www.usp.org/reporting/review/rev_076b.htm>
 Nonproprietary (“generic”)
names are generally preferred
over brand names
• Less confusing
• May be less expensive
 Posology
• Study of dosing
• Three methods of adjusting dose for children
– Clarks rule: weight (lbs)/150 = fraction of adult dose
– Young’s rule: age (yr)/[age + 12] = fraction of adult
dose
– Surface area: nomograms using weight and height to
determine fraction of adult dose
 Metric equivalents of some
common household measures
Household measure Metric volume
1 drop 0.05 mL
1 teaspoon 5 mL
1 tablespoon 15 mL
1 teacup 120 mL
1 glass 240 mL
1 pint 480 mL
 Approximate apothecaries’ and
metric equivalents
Weight Volume
Apothecaries’ Metric Apothecaries’ Metric
1/65 grain 1 mg 1 minim 0.06 mL
1 grain 65 mg 16 minims 1 mL
15 grains 1g 1 fluid dram 4 mL
1 dram 4g 1 fluid ounce 30 mL
1 ounce 30 g 1 pint 480 mL
 Components (3)
• Subscription
– Directions to the pharmacist, usually only how
much to dispense.
 Subscription

Lotta Celiva
Adult
You decide (pharmacist often fills this out for you)
11/5/01
Atropine sulfate 0.4 mg
Dispense 2
tablets
 Components (4)
• Signature (Label)
– Directions to the patient. What the pharmacist
puts on the label. Write in English for better
compliance.
 Signature (Label)
Lotta Celiva
Adult
You decide (pharmacist usually fills this out for you)
11/5/01

Dispense 2
tablets
Label: Take 1 tab 2 hours
before dental
appointment.
 Indication
DEA # BC1276899
Rex Reiter, M.D.
136 Wright Way
Boston, MA 02111
Drug indication on the
1-587-822-5536
(1-JUST CALL ME) label is useful not only to
Name Mr. Slim Foote
Address 2001 Pathway Road., Lane, MA 02101 Date 2/02/02
reduce potential filling
 (please print) errors, but to improve
patient knowledge of their
Terbinafine for onychomycosis 250 mg tabs
drugs. Pharmacy law only
Disp: #30
allows labeling for what is
written on the prescription.
If it doesn’t say what it’s
M.D.
for, it can’t be put on the
LABEL label.
REFILL TIMES PRN NR
INTERCHANGE MANDATED UNLESS
THE PRACTICIONER WRITES THE WORDS
‘NO SUBSTITUTION’ IN THIS SPACE
 Route/Frequency
DEA # BC1276899
Rex Reiter, M.D.
136 Wright Way
Boston, MA 02111
1-587-822-5536
(1-JUST CALL ME)

Name Mr. Slim Foote

Address 2001 Pathway Road., Lane, MA 02101 Date 2/02/02

 (please print)
Terbinafine for onychomycosis 250 mg tabs
Disp: #30

Sig: tabs 1 PO qd for 12 weeks

M.D.

LABEL
REFILL TIMES PRN NR
INTERCHANGE MANDATED UNLESS
THE PRACTICIONER WRITES THE WORDS
‘NO SUBSTITUTION’ IN THIS SPACE
 Common Abbreviations in
Prescription Writing
• qd or od = every day • po = by mouth (orally)
• qod = every other day • IV = intravenous
• bid = twice daily • IV push or bolus = at one time
• tid = thrice daily • IV infusion = infuse over time
• qid = four times/day • IM = intramuscular
• ac = before meals • stat = immediately
• pc = after meals • sq or sc = subcutaneous
• hs or qhs = at bedtime • sig = signa or signetur - label or
write or let it be labeled =
• disp = dispense
directions for use
• prn = as needed
 Components (5)
• Refill order
– Limited for controlled substances. Rarely required in
dentistry
• Prescriber’s signature and address
– Be sure to include DDS after name Prescriptions for
controlled substances will require address and DEA (
Drug Enforcement Administration) number and may
have to be prescribed on a special triplicate blank
Lotta Celiva
Adult
You decide (pharmacist usually fills this out for you)
11/5/01
Atropine sulfate 0.4 mg
Dispense 2
tablets
Label: Take 1 tab 2 hours
before dental
appointment.
No Your Name, DDS 93555
Your Name, DDS
 Modifications for controlled
drugs
• Inscription
– May use trade name when much easier to write because
of analgesic combinations
• Subscription
– Special technique for dosage number to avoid
prescription alteration
• DEA number
• Schedule II drugs cannot be called in except for an
emergency (real emergency)
 Controlled Drugs Prescriptions
Handwritten


NAME, FORM & STRENGTH of drug and dose


Morphine sulphate SR tablets 10mg 20mg bd
Methadone liquid 1mg/ml 10ml bd


TOTAL QUANTITY in WORDS and FIGURES


50 (Fifty) tablets

20 (twenty) ml


YOUR Signature and DATE


Iva Payne
Adult
You decide (pharmacist usually fills this out for you)
11/5/01
Vicodin (acetaminophen and hydrocodone)
Dispense twenty-four (24)
tablets
Sig: Take 2 tab every 4-6 hr
for pain

No Your Name, DDS 93555

Your Name, DDS AN1234567
 Common Prescribing Errors
 Wrong drug (e.g. drugs that sound alike)
 Wrong dose
 Inappropriate Units
 Poor/illegible prescriptions
 Failure to take account of drug interactions
 Omission
 Wrong route/multiple routes (IV/SC?PO)
 Calculation errors (important in Paediatrics)

 Multiple dose changes

 Some Ways of Avoiding Prescription
Errors
• Write Legibly
• Do not Guess
• Be Careful with “look alike”
• Avoid abbreviations
• Avoid multiple route
prescribing (i.e. im/sc/po)
• Avoid ten-fold dosing errors:
write 1 mg instead of 1.0 mg
• Conversely, write: 0.250 mg
rather than .250 mg; do not
chance losing a decimal point
• Write 4 times per day NOT
1x4 daily; Is this qid or for 4
consecutive days?
 Now let’s take a look at a
sample prescription.

See if you can spot any errors

in it.
 Portrait of a Poor Prescription

What is the first drug on this prescription? See next slide.

Source: AMA Web-site: www.ama-assn.org/sci-pubs/amnews/pick_99/prr21122.htm
 This was intended by the physician to be a
prescription for Isordil, the nitrate isosorbide
dinitrate. Plendil, the dihydropyridine
calcium channel blocking agent felodipine,
was erroneously dispensed by the
pharmacist because of the illegibility of the
prescription.
What happened?

The patient took Plendil, a calcium channel blocker, at an

increased dose, had a hypotensive episode and died.

A law suit was filed against the prescribing physician and

the dispensing pharmacist. Both were found negligent and
had to pay a $450,000 damage award jointly.
 CASE #2

Poor handwriting contributed to a medication dispensing error

that resulted in a patient with depression receiving the antianxiety
agent Buspar 10 mg instead of Prozac 10 mg
 CASE #3

A hypertensive patient accidentally received Vantin 200 mg

instead of Vasotec 20 mg when a pharmacist misread this
prescription