Setting

This audit will be relevant to all in-patient psychiatric settings where a high proportion of patients are prescribed medication ‘as required’ (p.r.n.).

Background

Prescribing p.r.n. is a common but valuable facility. Nonetheless, it is open to misuse and may be unnecessary or inappropriate (Department of Health, 2000). The Department of Health in 2000 committed itself to reducing serious prescribing errors by 40% by 2005. Prescribing errors are a daily occurrence in mental health trusts. The prescribing of p.r.n. antipsychotics is a contributor to combined and high-dose antipsychotic medication.

Standards

There are no national published ‘gold standard’ guidelines for p.r.n. prescribing. Generic standards were therefore obtained from the local trust's medicine policy and based on good clinical practice and principles (these could be used as a template for other teams aiming to audit the use of p.r.n. medication). All p.r.n. prescriptions should:

ᐅ use generic names (albeit with some exceptions)

ᐅ have a specified route of administration

ᐅ have each administration route prescribed separately

ᐅ show the maximum dose allowed in 24 hours

ᐅ show the minimum interval required between doses

ᐅ indicate whether the same drug (or class of drug) is also prescribed regularly

ᐅ involve only one drug from any one therapeutic category of the British National Formulary (BNF) (Joint Formulary Committee, 2009)

ᐅ be within BNFlimits, unless high-dose prescribing is consented to (and, where more than one route is prescribed, in total this should still be within BNFlimits or cross-referenced)

ᐅ have a specified review date and/or be reviewed at least once per month

ᐅ be cancelled if not used for longer than 1 month

ᐅ be reviewed if used on a regular basis (daily, for longer than 72 hours)

ᐅ have clear indications for use

ᐅ be rewritten if there are any alterations in the prescription. The target is that these standards are met for all patients.

Method

Data collection

Data were collected over a 3-month period covering all the in-patients. Medical case records and drug charts were reviewed retrospectively. All p.r.n. prescriptions were reviewed against the standards.

Data analysis

The total percentage of compliance with the above standards was analysed using spreadsheet software.