NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Primary Care

PostScript Primary Care - Sept 2012

10 Golden Rules for Safe Controlled Drug Use

Anyone who has an incident involving a controlled drug is required to report it to the Accountable Officer. We have tried to pick out a few themes from these reports to highlight common problems. Think about whether you need to review your practice to reduce the chance of making a similar error.

  1. Received CDs? Record what, when, where from and how many. And record it in a legally compliant CD register.

  2. Used or supplied a CD? Record who got it, how much and when. Do this as soon as possible.

  3. If you are supplying a CD to a patient and something seems a bit strange, stop and double check. If the Oramorph® is pink instead of clear you should pause and wonder why. It's pink because it's 100mg/5ml rather than 10mg/5ml. You don't want to be responsible for a ten-fold overdose. Oh, and that’s also why the original pack is a different size and the label is a different colour from what you expected.

  4. Prescribing or ordering CDs on computer? Check you've picked the right item from the drop down menu. Oxycodone capsules and tablets are very different and have different dosing schedules. Buprenorphine patch 20mcg/hour is changed every seven days; the 35mcg/hour patch is changed every 4 days.

  5. If you are giving out methadone check you have the right patient. It sounds simple, but you'd be surprised how often people get given the wrong person's dose. Why not ask the patient what dose they expect?

  6. A new patient getting very high doses of MST® or another opioid? Check with the person collecting the prescription if they have had it before and the dose if possible. Prescriptions aren't always right.

  7. Don't destroy stock CDs without the presence of an authorised witness. It doesn't matter who the stock belongs to. GPs and pharmacists are subject to the same rules. Phone the CD team to arrange destruction.

  8. Patients or their representatives can return dispensed CDs no longer required to community pharmacies. Pharmacists should keep records of what is returned and when it is destroyed. This doesn't need an authorised witness but for good practice you should still have a witness (eg another member of staff). GP practices should not accept medicines returned from patients.

  9. If you have stocks of CDs on your premises or in your possession, you are legally required to have written standard operating procedures covering every action with CDs. Make sure that you have read and understand them and that you follow the processes. SOPs aren't there to inhibit your freedom of expression. They are there to minimise risks and safeguard patients. Most of the incidents reported can have the causes traced back to someone not following the SOPs. If the worst happens, how could you defend that?

  10. Got problems with CDs such as missing stock or do you have concerns about something you have seen related to CD use? Phone the CD team on 0141 201 5348 for calm, helpful and proportionate advice.

Safe Use of Non-insulin Therapies training

NHS Diabetes has launched a new free e-learning module on the safe use of non-insulin therapies, available HERE; The module is aimed at all healthcare professionals who are involved with patients relying on non-insulin therapies, and is designed to improve knowledge and confidence in their safe and effective use.

The aim of the module is to improve patient safety by reducing the number who experience medication errors and/or poorly controlled blood sugar levels while utilising non-insulin therapies, both of which are potentially life threatening.

Advice regarding prescribing and dispensing of Dermatology Preparations

It is now advised that the dilution of a topical steroid preparation is never clinically necessary - all required potencies can be met from the existing commercial preparations.  There are concerns about stability and potency of mixtures as well as the unlicensed nature of the mixtures.

It is never appropriate to mix a coal tar, ichthammol or salicylic acid preparation with a steroid preparation (again due to stability issues and potential unknown effects on the potency of the steroid caused by the change in pH).  If they are prescribed together they should be applied as two separate preparations.

Dilution of steroids will affect the pH of the preparation and may also affect the particle size of the active ingredient.  This could lead to unintended effects on the potency e.g. a decrease in particle size could lead to increased absorption of the drug and increased potency.  It is impossible to quantify this or predict the effect.

Most topical steroids are more stable at acidic pHs.  Ichthammol and coal tar are alkaline and will decrease the stability of the steroid.

In addition, it is advised that Coal tar or salicylic acid preparations should be prescribed as standard concentrations (e.g. 1%, 2%, 5%, 10%, 15% and 20%).  Yellow soft paraffin can be used as a base instead of white soft paraffin (there is no therapeutic difference and standardising on YSP will allow economies of scale). There is no clinical need for half strength Lassars paste, which has now been removed from the approved list.

The above guidance has been endorsed by NHS GGC Dermatology Formulary Review Group.

Prescribers and community pharmacists should be aware of this advice when they are prescribing or dispensing unlicensed or extemporaneously prepared dermatology products. This guidance has now been included in the NHS GG&C “Guidance on the Use of Specials in Primary Care”. Available HERE

References:
"Critical formulation aspects of local corticosteroids" - Europoean Journal of Hospital Pharmacy Practice vol 17 2011 p60-61"

Dr Colin Cable, Royal Pharmaceutical Society Pharmaceutical Sciences Information Advisor.

Tamiflu® Suspension

Please note the change in concentration for Tamiflu® suspension and the recommendation for prescriptions to state the dose in millilitres.
Community pharmacists are advised to check with the prescriber if there is any doubt about the intended dose.

PPIs and hypomagnesaemia

NHSGGC Biochemistry would like to clarify the advice provided in PostScript 70 (July 2012). If a patient is on a PPI, measuring magnesium is now recommended only for patients who:

  • have symptoms of hypomagnesaemia
  • have hypokalaemia or hypocalcaemia
  • are taking digoxin
  • have other causes of magnesium deficiency, eg prescribed diuretics, malabsorption syndromes, stoma losses.

Orlistat supply problem resolved

The main supplier of orlistat (Roche), have reported that 120mg orlistat (Xenical®)is now available through all wholesalers.