Zero tolerance prescribing
Prescription and fluid chart writing on PICU
These rules apply to fluid charts and drug charts.
Who writes the charts?
Only PICU registrars, PICU consultants, and PICU indeendent prescribers (i.e. PICU Advanced Nurse Practitioner and PICU pharmacist) may write in drug charts on the unit - only prescriptions written by this group will be given. This means that all new admissions require a new drug chart, even if they come from within the hospital. The exceptions are for post-operative and oncology patients - their charts do not need to be re-written.
Exceptions - the following prescriptions written by non-PICU staff are acceptable:-
Post-op analgesia and antiemesis may be prescribed by an anaesthetist
Epidurals, PCA and NCA infusions will be prescribed by an anaesthetist
Peri-operative antibiotics prescribed by the surgical or anaesthetic team
Chemotherapy agents prescribed by the oncology team
Where are the charts written?
Writing drug charts is often done in a fairly casual way, and treated as a relatively routine part of the job - this is not acceptable on PICU. It is a key part of the patient's management, and is equal in importance to taking an accurate history and conducting a physical examination, and should be accorded the same respect.
This means that drug charts and fluid charts should be written by the doctor in an office or sitting at a desk free of interruptions. Nursing staff have been asked not to interrupt while writing prescriptions. Interruptions are no more acceptable while prescribing that they would be while involved in history taking, examination or speaking to parents. But use your common sense, and take yourself to a place where you are less likely to be interrupted.
Writing a chart at the bedside invites interruptions - it is not acceptable on PICU.
Writing a chart on the ward round means the prescriber is not concentrating on the ward round, or not concentrating on prescribing, or most probably not concentrating fully on either - it is not acceptable on PICU.
Do not write prescriptions on ward rounds
Do not write prescriptions by the bedside
When charts become messy, or additional charts are used, mistakes are more likely. It is therefore sensible to re-write a chart. However, there is then a risk of transcription errors, so again full attention has to be given to this task. Re-writing a chart is seldom a matter of urgency, so unless there are exceptional circumstances, charts are only to be re-written between 10am and 12pm, and nursing staff know not to request it outside these hours. Our pharmacist then reviews the charts in the early afternoon to ensure there are no mistakes.
Re-writing involves re-calculating dosages and re-considering the need for drugs - it is not a simple copying exercise.
Checking dosage and administration routes
Doses should always be checked with a reference source (usually childrens BNF or a consultant written instruction) - don't rely on memory.
If you ask a consultant or nurse on the unit for the dose the stock response will be 'look it up'.
For unusual dosages which are not in commonly used references, the dose should be recorded in the inpatient notes together with the consultant authorising, or a literature reference.
If a member of staff or a patient/ relative indicates that they think the drug or dose is wrong, go back to the beginning and start again - a common theme in serious drug errors is someone (often a relative) thought the wrong drug was being given in the wrong amount or in the wrong way, but were ignored.
The drug calculator on the website is a useful resource - but the doses still need to be double checked.
The following commandments are unbreakable. If your prescription breaks any of these rules, the nursing staff will refuse to give the drug, and you will have to re-write the prescription. The nurses have the full support of the consultants in this.
All prescriptions must be written in ink in legible block capitals, and signed by the prescriber. The drug chart should show the name, date of birth and hospital ID of the patient, and the patient's weight should be recorded.
Check the patient's allergy status - if the box is blank, this means it has not been checked, and drugs will not be given. If it is impossible to ascertain allergy status, (no carer available to give history) 'none known' can be entered.
Avoid unnecessary decimal points
3mg not 3.0mg
500mg, not 0.5g
when unavoidable, write a zero in front of the decimal point where there is no other figure - 0.9% saline, not .9%
micrograms, nanograms - write in full, not mcg or ng - no abbreviations, no Greek.
ml or mL, not cc or cm3
Use only approved generic names for drugs (see BNF), and do not use abbreviations. Buccolam® is an exception to this rule
Specify only one route of administration e.g. oral/ PR is acceptable as both routes are enteral (provided the oral and PR dose for that drug are the same) but IV/ Oral is unacceptable
Specify only one route of administration (e.g. oral/ PR is acceptable as both routes are enteral but IV/ Oral is unacceptable)
On discontinuation of a prescribed drug, the "crossing off" should occur through the prescribing section of the chart (i.e. the boxes containing the name of the drug, dose, frequency etc.) and through the section of the chart used to record administration of the drug. The crossing off should be signed and dated.
Source of reference.
All prescriptions need to be checked with a written source. The default source is the Children's BNF - most recent edition.
If the written source you are using for the prescription is different to Children's BNF, the source should be coded for adjacent to the prescription:-
|Alternative formulary||AF||Formulary name, page number.|
PICU Consultant order
|PCO||Consultant name. This may include a journal or abstract reference.|
|Non PICU team||NPT||Consultant name, signature of team member|
A sheet will be inserted at the front of all patients nursing notes to record the specific sources for AF, CA, NPT.