Professional guidance to support prescribing and dispensing / supply / administration by the same healthcare professional

What is this document for? 

This document contains professional guidance to support the implementation of policy to ensure prescribing and dispensing by the same healthcare professional, when this is necessary, is safe and appropriate. 

When is it acceptable for prescribing and dispensing by the same healthcare professional to take place?  

It is considered necessary and acceptable, when the clinical circumstances of an episode of care mean it is in the interests of the patient for the same healthcare professional to be responsible for the prescribing and dispensing, supply or administration of medicines in routine practice.  

Does there need to be a system-level risk assessment?  

To safeguard patient safety, there must be a robust risk assessment conducted, documented and available to colleagues providing the service. This is to ensure the service is appropriate and risks are identified and mitigated. 

It is the responsibility of the organisation to undertake the risks assessment and should be developed in collaboration with team members involved in prescribing, supplying and administration.  

Risk assessment documentation should cover:  

1. Why – A descriptor of why there is a clinical need for prescribing and dispensing, supply or administration by the same healthcare profession for the activity 
2. Which medicines or conditions treated – A list of medicine or list of classes of medicines or a list of clinical conditions treated should be part of the risk assessment documentation, this may be refer to or be in the form of a local formulary or sections of a national formulary for dosing information, other examples include referral to NHS services contractual documentation where applicable
3. Risks – The risk assessment should identify the possible risks, their likelihood and impact
4. Mitigation – The risk assessment should describe mitigations to reduce impact of risks. Mitigations may include:  
   • Staff skill-mix and an accuracy check from a pharmacy technician   
   • The appropriate use of evidence-based technology  
   • Ensuring mental breaks between critical activities within standard operating procedures. 
5. Expectations around audit of services –  
   • A descriptor of recording keeping appropriate for the activities  
   • A descriptor of intended periodic audit/research to build up evidence base of safe and effective care. 
6. Frequency – The risk assessment should consider and state an appropriate frequency of review and circumstances where it might need to be revisited more frequently, for example, where:  
   • A near miss has been identified  
   • A prescribing or dispensing error has taken place
   • There’s a change in the formulary/medicines which are prescribed and dispensed, e.g., if a medicine outside of the documented list is deemed suitable for prescribing, administration or supply.  

What can individual prescribers do to maximise patient safety if prescribing and then dispensing, supplying or administering? 

Prescribers can improve patient safety by ensuring:  

1. The service is within their personal scope of practice  
2. They maintain and keep an up-to-date personal formulary or other indication of scope of practice 
3. Medicines are prescribed and dispensed within recognised clinical prescribing guidelines 
4. Use of a mental break to separate activities of prescribing, clinical check, accuracy check and dispensing 
5. They meet all relevant competencies identified in the RPS competency framework for all prescribers 
6. They communicate with the person being treated or their representative and, following dispensing, have a conversation with the general practice of the person being treated about the medicines prescribed and dispensed. 

Case studies

Case study 1 – Sexual health clinic prescribing against a limited formulary  

A patient presents to the service for emergency contraception. She is seen by the nurse who is a prescriber and assessed. The nurse makes the decision to treat the patient with emergency contraception. As this is a time critical treatment the nurse who is a prescriber, issues the prescription and then supplies the medication to the patient with clear instructions on how and when to take it. This is done under an agreed risk assessment and is a process used by the whole prescribing team as this medication is time critical. To reduce the risk the medication is stored separately to other medication and is clearly labelled so that the prescriber can add the patients name and date of birth.  

In this situation, issuing a prescription reduces the potential for compliance as the patient will need to go to a pharmacy, causing delay and potentially reducing the effectiveness or ability to administer to outside of the recommended treatment window.  

Case study 2 – community pharmacy prescribing against a limited formulary  

A 58 year old man hobbles into the pharmacy with pain in a swollen big toe. The pharmacist recognises classic symptoms of gout.   

During a private consultation the man describes waking up with excruciating pain and unable to put weight on his foot. Previous gout attacks have been managed by his GP with naproxen but a review of his current medication shows a diuretic for blood pressure has recently started and there is a contra-indication with naproxen and other NSAIDs due to kidney complications.  

The pharmacist reviews options and determines colchicine may be effective to control gout flares, however this is outside the usual supply list in Wales. The pharmacist reviews her British National Formulary and Medicines Complete, confirming colchicine appropriateness in this case. The pharmacist double-checks references, verifies the assessment and ensures informed consent, ultimately prescribing and dispensing the colchicine and prioritising the man’s need for immediate relief and wellbeing.  

The episode of care sparks the pharmacists desire to formally expand scope of practice in this area and following further reflection and research he revises his personally formulary and risk assessment protocols to include colchicine.  

Case study 3 – Acute prescribing and dispensing or administering to people in their homes  

An ANP attends a patient’s home in the middle of the night when working with out of hours services. Following a full assessment, the patient is diagnosed with an acute exacerbation of COPD caused by a respiratory infection. The patient’s oxygen saturation levels are low but not low enough for hospital admission. The ANP administers a salbutamol nebuliser and starts the patient on oral antibiotics and steroids. She is keen for the patient to start treatment as soon as possible to reduce the risk of hospital admission but the pharmacy is not open until the next morning. 

To improve potential outcomes and reduce the risk of hospital admission, the nurse gives the patient enough medication for their first dose of prednisolone and three doses of antibiotics, giving the patients family time to collect the medication but preventing the inevitable delay in getting the medication needed. 

The ANP writes prescriptions to cover the supply of medicines made and a prescription for additional further supplies which might be needed from a pharmacy.  

Administering a short supply of medication to improve the patient’s outcomes and reduce the risk of hospital admission is written into the Prescribing and administering risk assessment for out of hours. This is audited regularly to ensure compliance and accuracy.