A wise man once told me that the most dangerous thing in the hospital is an intern with a pen and, if you think about it, it’s probably true. Prescribing can be difficult and stressful when you first start out, but it doesn’t have to be. There are lots of experienced people around you to help you out, including your consultants and registrars, residents and pharmacists. However, there are also some ways you can help yourself out:
Day one of internship is many things – exciting, challenging, overwhelming. Make it a bit easier by having some drug doses memorised. Each specialty will have its own high rotation drugs that you will learn about during the term, but there are some medications that you will use every day in every term. Before you start, I would suggest looking up (and committing to memory) the doses of:
The best way to be a safe prescriber is to understand the drugs and fluids you are prescribing and to ensure your orders are unambiguous. Always ask yourself ‘could this be misinterpreted?’ If you have terrible handwriting, you need to do something about it. My cursive writing is a bit unreadable at times, so I print drug orders in block letters. Errors can also occur if you prescribe using brand names (except for combination products such as Panadeine Forte) or use unapproved abbreviations. Some of these things can seem like a huge chore but they are important. Remember, you don’t want to be the most dangerous thing in the hospital!
If you don’t know what it is or how much you need to give, you probably shouldn’t chart it. If you are on a ward round and your registrar or consultant casually says ‘chart some antibiotics’, make sure you ask them which antibiotic and what dose. This gets easier with experience.
MIMS will always give you a dose, but it can be cumbersome to work through the full product information. The Australian Medicines Handbook is a good quick reference and has doses for unapproved indications. Therapeutic Guidelines will usually give you the most specific prescribing information for a particular indication. They are especially useful for antibiotics. The Australian Injectable Drugs Handbook is great for finding out whether you can give drugs by an alternative parenteral route (when no one can get that cannula in) and for guidelines about IV electrolyte replacement. Don’t forget your ward pharmacist is a useful resource and often will know obscure drug doses off the top of their head.
Pretty self-explanatory, but it is much easier to prescribe a heparin infusion for the first time if you have at least a passing knowledge of the chart. The National Inpatient Medication Chart is used everywhere, so get used to it. Insulin charts are often confusing, so spend some time reading that one. A trick for young players – fill in all of the ‘doctor’ parts of your charts. It will save you much time and harassment if you just do it when you first write up the chart.
Elderly patients’ bodies do crazy things to drugs. And drugs do crazy things to their bodies and minds. The pharmacokinetics and pharmacodynamics of medications are altered in the elderly, particularly if they are frail. The guidelines for many drugs recommend reduced doses or altered dosing schedules in the elderly and this should be in the back of your mind whenever you see an elderly patient (ie every day).
Children are also special. Always, always, always look up the mg/kg dose of a drug before you prescribe for a child. The Royal Children’s Hospital Pharmacopoeia provides unambiguous monographs and paediatric doses. Always prescribe in milligrams, not millilitres of syrup, as many medications come in multiple concentrations.
Patients with renal or liver dysfunction often require dose alteration. When in doubt, look it up.
Provider and prescriber numbers can be very confusing. Your provider number allows you to access Medicare benefits on behalf of your patients for things such as blood tests or imaging. It allows the hospital to claim money from the federal government for the tests you order. You need to have one provider number for each hospital that you work at. A prescriber number allows you to access subsidised medications through the Pharmaceutical Benefits Scheme (the PBS). This is not important for inpatient prescribing or discharge prescribing in NSW hospitals, as these medications are funded by the state government and aren’t eligible for PBS (federal) funding. However, there will be occasions when you have to write PBS prescriptions, such as for patients being discharged from emergency or patients discharged on weekends. There is a generic hospital prescriber number, but you will need one eventually so you may as well get your own now. You can apply for it at the same time as you apply for your provider number.