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.