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Community Pharmacy audit on Dental Prescriptions

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Community Pharmacy audit on Dental Prescriptions Powered By Docstoc
					Joanne Clarke, Medicines Governance Pharmacist
November 2009


                     Community Pharmacy audit on Dental Prescriptions
                                   June or July 2009

Introduction
Dental prescribing cannot be monitored through the Prescription Pricing Division (PPD) as easily as
GP prescriptions. One way of monitoring the prescribing by dentists is by analysing the
prescriptions that are dispensed within a community pharmacy.

The Department of Health is working with prescribers to ensure the appropriateness of antibiotic
prescribing. The Health Protection Agency has noted in its latest report that there is an increasing
prevalence of antimicrobial-resistant micro-organisms especially multi-resistant strains1. This has
reinforced the need for prudent use of antimicrobials. They also suggest that surveillance of
antimicrobial prescribing is required. A part of this audit will investigate the analysis of dental
prescribing of antibiotics.

Under the Clinical Governance Essential Service in the Pharmacy Contract, all pharmacies are
required to participate in a multidisciplinary audit each year.

Aim
To ensure that drugs prescribed by Dentists within NHS Wiltshire are appropriate and to establish if
there are any issues that occur when Pharmacists come to dispense the prescriptions.

Results
65 out of 68 community pharmacies completed this audit (response rate of 96%). Each pharmacy
chose whether to complete this audit in June or July. A total of 2013 items were dispensed.

1809 items (89.9%) were for NHS patients, 203 (10.1%) were for private items. There was 1 item
which was written on a NHS form but was an old form. The pharmacist did not know whether this
was a legal form as the dentist normally writes private prescriptions. This was charged as a private
prescription and then questioned with the dentist.




1
  Health Protection Agency. Antimicrobial Resistance and Prescribing in England, Wales and Northern
Ireland, 2008. London: Health Protection Agency, July 2008.


                                                                                                       1
                                                                                                                  Number of items                                                                                                                                                             Number of items
                                                                   Am                                                                                                                                                                        Ad




                                                                                               0
                                                                                                   10
                                                                                                        20
                                                                                                             30
                                                                                                                        40
                                                                                                                                50
                                                                                                                                     60
                                                                                                                                          70
                                                                                                                                                                          80
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                                                                                                                                                                                                                                                                                                    100
                                                                                                                                                                                                                                                                                                          120
                                                                                                                                                                                                                                                                                                                140
                                                                                                                                                                                                                                                                                                                      160
                                                                                                                                                                                                                                                                                                                            180
                                                                                                                                                                                                                                                                                                                                                       200




                                                                                                                                                                                                                                                                           0
                                                                                                                                                                                                                                                                               20
                                                                                                                                                                                                                                                                                    40
                                                                                                                                                                                                                                                                                         60
                                                                                                                                                                                                                                                                                              80
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                                                                                                                                                                                                                                                                                                                                                             November 2009




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                                                                                                                                               Total number of items of
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                                                                                                                                                                                                                                                                                                                              of amoxicillin = 934




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                                                                                                                                                                                                                                                                                                                              Total number of items




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                                                                                                                                                                                                                                                                                                                                                             Joanne Clarke, Medicines Governance Pharmacist




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    Figure 2 – Items prescribed privately (n=203)
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                                                                                                                                                                               Figure 1 – Items prescribed on the NHS (n=1809)
                                                                              ed
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                                                                                                                                                                                                                                                                                                                              Total number of items
                                                                                                                                                                                                                                                                                                                              of metronidaozle = 465




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2
Joanne Clarke, Medicines Governance Pharmacist
November 2009


Figures 1 and 2 show that the majority of prescriptions written by dentists are for amoxicillin
(n=934, 52% for NHS and n=110, 54% for private) and metronidazole (n=465, 26% for NHS and
n=60, 30% for private).

The next highest drug dispensed was sodium fluoride prescribed on the NHS (n=140, 8%). There
were no items of this prescribed on private prescriptions. 63 of these items (45%) were for under
18 year olds.

Amoxicillin (n=1044)

Table 1: Dosage frequency of amoxicillin

Dosage frequency             Number of     Percentage    Comment
                             prescriptions of
                                           prescriptions
Three times daily            992                 95%                Correct frequency
Twice daily                  3                   0.3%               Subtherapeutic
Four times daily             17                  1.6%               Above recommended frequency
1 double dose and            8                   0.8%
then normal dose
3g prophylaxis               20                  2.0%               Not recommended by NICE2
3g then another 3g 8         2                   0.2%
hours later
2 x 3g daily for 2 days      1                   0.1%
500mg at once                1                   0.1%

This shows that 1.6% of the amoxicillin items were for a dose frequency above the recommended
one. 0.3% were for a subtherapeutic frequency.

Table 2: Dosage forms for amoxicillin

Dosage form                  Number of     Comment
                             prescriptions
Capsules                     539                 Correct form
Suspension                   57                  Correct form
Sachet                       23                  Correct form
Tablets                      29                  This form does not exist
No form on                   27
prescription

648 items (62%) of amoxicillin had a form written on the paperwork. Of the 396 items that didn’t
have a form stated on the audit paperwork, 27 had written that no form was present on the
prescription. The other 369 either had no form on the prescription or the pharmacy did not include
this on the paperwork. Therefore no percentage can realistically be formed as 369 items are of
unknown form.




2
    NICE. Prophylaxis against infective endocarditis. Clinical Guideline 64. March 2008.


                                                                                                     3
Joanne Clarke, Medicines Governance Pharmacist
November 2009


Metronidazole (n=525)

Table 3: Dosage frequency of metronidazole

Dosage frequency           Number of     Percentage    Comment
                           prescriptions of
                                         prescriptions
Three times daily          507                   97%              Correct frequency
Twice daily                10                    1.9%             Subtherapeutic
Four times daily           3                     0.6%             Above recommended frequency
400mg at once              1                     0.2%
200mg x2 at once           2                     0.4%
then 1 three times
daily
1 tablet to complete       1                     0.2%
course
No frequency               1                     0.2%
reported on
paperwork

Table 3 shows that 97% of items for metronidazole were of the correct frequency.

Table 4: Dosage forms for metronidazole

Dosage form                Number of     Comment
                           prescriptions
Tablet                     287                   Correct form
Suspension                 4                     Correct form
Capsule                    4                     This form does not exist
No form on                 15
prescription

295 items (56%) of metronidazole had a form written on the paperwork. Of the 230 items that didn’t
have a form stated on the audit paperwork, 15 had written that no form was present on the
prescription. The other 215 either had no form on the prescription or the pharmacy did not include
this on the paperwork. Therefore no percentage can realistically be formed as 215 items are of
unknown form.

Other antibiotics that were prescribed were (number of items in brackets):
    Erythromycin (78) – 3 items were for capsules which is not allowed on a FP10D, 18 items
       were for a dose of three times a day where it should be twice or four times daily.
    Penicillin (30) – 5 items were for a dose of three times a day which is lower than the
       therapeutic dose.
    Clindamycin (28)
           o 150mg, four times daily – 9 items
           o 150mg, three times daily – 7 items
           o 250mg, three times daily – 1 item – this strength does not exist
           o 300mg, three times daily – 5 items
           o 300mg, four times daily – 1 item



                                                                                                4
Joanne Clarke, Medicines Governance Pharmacist
November 2009


            o 450mg, three times daily – 2 items
            o 500mg, four times daily – 1 item – this strength cannot be attained
            o 600mg, three times daily – 1 item
            o 600mg as a single dose – 1 item
       Cefalexin (15)
       Doxycycline (4) – 1 item was for doxycycline tablets 20mg, twice daily for 7 days which is
        not the length of treatment stated in the BNF. The pharmacist also did not query it. 1 item
        was for doxycycline tablets 20mg, twice daily for 90 days which is the length of treatment
        stated in the BNF.
       Tetracycline (2)
       Clarithromycin (2)
       Co-amoxiclav (2)
       Flucloxacillin (1) – this was prescribed three times a day which is below the therapeutic
        dose of four times daily.

Other drugs that were prescribed were in much fewer numbers of items. There were 140 items of
sodium fluoride dispensed during this audit. This was a mixture of toothpaste and mouthwash.
Some dentists are prescribing one tube of toothpaste or one bottle of mouthwash, whereas others
are prescribing more quantities at a time. An action point following on from this audit is to
investigate whether this is appropriate prescribing of sodium fluoride as it appears that not all
dentists are prescribing it and others are prescribing much more. This work will need to include the
public health team and dental experts to establish best practice.

Problems with prescriptions

50 items out of 2013 (2.5%) required the pharmacist to contact the dentist. These are included in
Appendix 1.

335 items out of 2013 (17%) were reported to have had a problem by the pharmacist. These are
included in Appendix 2.

Some of the points that were raised by pharmacists are not valid as they identified factors that are
desirable and not legal requirements, however, there were some points that need further
investigation:

       Some dental prescriptions are not fulfilling all legal requirements eg address of dentist, age
        of child if under 12, patient name and address, date of the prescription
       Clindamycin use – a prescription for 600mg three times daily was queried but the dentist
        confirmed that this was the dose required. This is above the recommended BNF dose.
       Quantities missed from the prescription
       Drugs or form of a drug that does not exist and are not allowed on a prescription eg
        amoxicillin tablets

Conclusion and comment

2013 items prescribed by dentists were analysed. The majority of prescriptions from dentists were
for amoxicillin and metronidazole, however, there were prescriptions for other antibiotics, antifungal
drugs, mouthwashes and toothpaste. The analysis on the drugs shows that the majority of
prescriptions are for the correct frequency for the drug. The main action point from this audit will be
to produce guidance on prescribing for local dentists so that the legal aspects of a prescription are


                                                                                                         5
Joanne Clarke, Medicines Governance Pharmacist
November 2009


correct. This work will be carried out by the Medicines Management Team. It will be a large piece
of work, therefore in the interim period, a brief ‘handy hints’ guide will be produced. The Medicines
Management Team will also produce guidance for pharmacists as the audit results suggest that not
all pharmacists are aware of the differences between legal requirements and desirable information
on dental prescriptions.

Action points following the Dentist and Community Pharmacy audits

Two audits were carried out during 2009-2010 to establish prescribing patterns for dentists. They
were carried out by dentists (on the prescriptions they wrote) and by community pharmacists (on
the prescriptions they dispensed). The audits have been written up and are separate to this
document. This document outlines, further action points that follow from the audits.

       Education of dentists – this will be done in a number of ways following discussions with
        primary care and the LDC.
            o Legal requirements on a prescription as these are not always present
            o Desirable aspects to a prescription eg name of dentist, to aid the pharmacist when
               dispensing
            o Frequency of specific drugs namely antibiotics
            o Which drugs to use for which indication – a formulary is to be created. This is a
               long-term piece of work which will need input from experts in the field. However, a
               brief ‘handy hints’ is to be produced to aid dentists.
            o NICE guideline – Prophylaxis against infective endocarditis (Clinical Guideline 64,
               March 2008)
       Gather any concerns or questions from dentists around prescribing so that the Medicines
        Management Team can advise and help.
       Pharmacists to be aware of the legal requirements and desirable aspects of a dental
        prescription to avoid any unnecessary ‘phone calls to the dentist
       Sodium fluoride – investigate and analyse the use of sodium fluoride on prescription in
        primary care dentistry, gaining advice from local dental experts and the Public Health Team.




                                                                                                    6
Joanne Clarke, Medicines Governance Pharmacist
November 2009


Appendix 1

List of reasons why the dentists were contacted about the prescriptions

50 items out of 2013 (2.5%) required the pharmacist to contact the dentist. These were for the
reasons below:
       Amoxicillin dose of 4 x day changed to 3 x day after contacting dentist (x 5)
       No name/practice stamped on prescription
       No strength of amoxicillin (x 2)
       No strength of Ephedrine nasal drops.
       Quantity of corsodyl mouthwash
       ‘tds for 7 days’ or 14 capsules – conflicting information
       To confirm DoB (x 2) (although these patients were 14 and 58)
       No date on the prescription (x 5)
       Quantity of Amoxicillin
       Quantity of dihydrocodeine
       Dose of amoxicillin checked
       Dose and quantity of amoxicillin checked
       Patient allergic to penicillin and Flagyl but prescribed metronidazole
       No quantity for Corsodyl mouthwash
       Prescribed Perioguard – not allowed therefore alternative asked for
       No dental surgery stamp
       Amoxicillin tabs to caps
       Erythromycin capsules not allowed – change to tabs
       Dose of amoxicillin confirmed
       Confirm strength of Duraphat toothpaste (x 2)
       Miconazole cream – patient thought he had to use it in the mouth therefore ? should have been oral
        gel.
       Amoxicillin 250mg tabs prescribed 2 every 8 hours. Contacted dentist to see if they wanted 500mg
        caps every 8 hours.
       Nystatin ointment not allowed on FP10
       3x300ml sodium fluoride mouthwash prescribed. Not available so wanted to give 2 x 500ml
       To confirm dose as 1 tds looked like 2 tds
       Incorrect dose of amoxicillin
       Amoxicillin changed from 125mg/5ml to 250mg/5ml but didn’t change 10ml tds to 5ml tds
       Ibuprofen 250mg prescribed.
       250mg 2 tds amoxicillin changed to 1 tds
       Clindamycin 250mg prescribed. Confirmed as 150mg
       Clindamycin 600mg tds prescribed. Confirmed the dose with dentist therefore 96 x 150mg issued for
        an 8 day course.
       Incorrect address for patient and practice address was incorrect.
       Quantity of paracetamol suspension
       Quantity of triamcinolone paste
       Quantity of lidocaine ointment
       Quantity of benzydamine mouthwash
       Quantity of ibuprofen suspension
       Interaction of amoxicillin and methotrexate. Dentist asked pharmacist to liaise with surgery who
        approved script and arranged blood test.
       Clindamycin 300mg tds (30x 150mg) – bad handwriting therefore needed to check prescription




                                                                                                         7
Joanne Clarke, Medicines Governance Pharmacist
November 2009


Appendix 2

List of errors on the prescription (as reported by the pharmacists)

335 items out of 2013 (17%) were reported to have had a problem by the pharmacist. The reasons
are below:

       No form on the prescription (x45)
       Incorrect form (x26) – ie not allowed on FP10D eg amoxicillin tablets
       Prescribers name missing or illegible (x130) – not a legal requirement although what is a legal
        requirement is the particulars to indicate that the appropriate practitioner is a dentist. Therefore
        pharmacists need to make sure they are actually a dentist.
       No dentist stamp and therefore no name or address of prescriber (x7)
       No date of birth or age (x42) – 19 of these were for patients over 12 years old and therefore no date
        of birth is required on the prescription. 2 of these were under 12 years old which makes them invalid
        prescriptions. There were 21 patients where the age was unknown – 2 of these were prescribed
        125mg/5ml amoxicillin so therefore were probably under 12 years old making these invalid
        prescriptions.
       No date on prescription (x7)
       Comments about dentists writing in the endorsement margin (x27)
       One comment about the dosing and use of clindamycin (2x150mg tds x 30)
       Clindamycin – 450mg – strength not available so dispensed 3x150mg
       600mg tds clindamycin prescribed. Dose checked with dentist and 150mg x 4 tds – 96 capsules
        issued.
       Erythromycin 500mg qds x 28 prescribed. Issued 56 x 250mg tablets.
       Amoxicillin 250mg qds x 21 prescribed. Checked dosage and quantity with prescriber
       Qds amoxicillin was signed off by dentist on Rx
       Incorrect dosage
             o Erythromycin tds (x2)
             o Amoxicillin (tds reported as inappropriate dose) (x2)
             o Amoxicillin qds – changed to tds after contacting dentist
             o Metronidazole (tds reported as inappropriate dose)
             o Paracetamol (1g 4hrly reported as inappropriate dose)
             o Ibuprofen 400mg 4hrly
       Items not allowed on FP10 D
             o Perioguard wash
             o Erythroped suspension – although this is allowed
             o Nystatin ointment
       No quantity
             o Dihydrocodeine 30mg 4-6 hours for 5 days. Pharmacist dispensed 20 as assumed 4 daily
                  would be needed
             o Corsodyl mouthwash (x2)
             o Chlorhexidine mouthwash
             o Dihydrocodeine tab 30mg qds
             o Corlan pellets
             o Metronidazole – given 15 to match amoxicillin
             o Erythromycin suspension
       Interaction with methotrexate – dentist contacted who asked pharmacist to liaise with surgery. GP
        approved script and arranged for blood test.
       Incorrect address for patient and for practice
       Interaction with warfarin
       Clindamycin 250mg tds prescribed. Contacted dentist to agree 150mg.
       No dosage on metronidazole Rx – patient told tds
       No instructions for sodium fluoride mouthwash and toothpaste – new prescriptions


                                                                                                            8
Joanne Clarke, Medicines Governance Pharmacist
November 2009


       No instructions for corsodyl mouthwash
       No postcode (x3)
       No strength
             o Metronidazole tabs – patient sent back to dentist
             o Ephedrine nasal drops
             o Duraphat toothpaste – also no quantity or instructions
       Generic erythromycin not prescribed
       Patient’s first name not on prescription
       500mg qds x 20 of penicillin tablets. Dispensed 40 x 250mg
       Patient claimed to be allergic to penicillin and flagyl but prescribed metronidazole. Pharmacist sent
        script back to be changed
       Amoxicillin dose – struggled to read instructions but went with tds (x2)
       Vague directions on sodium fluoride mouthwash
       Metronidazole 400mg bd for 4 days – comment that it was an unusual dose – dentist not contacted
       Unfamiliar NHS form pre’96 – charged as per private. No dentist’s qualifications on Rx
       Incorrect address for patient (x2)
       3 items had no explanation




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