Drug selection
Problems relating to the choice of drug prescribed or taken
Duplication (D1)
When to Use:
When there are no obvious adverse
clinical effects of the
two
drugs together, but it is either inappropriate or very
unusual to see
them prescribed or used together as they are from
the same therapeutic class.
This also covers the specific compliance situation where
a person may
be inappropriately taking two brands of the
same
drug.
Examples of
when
to use:
• Patient prescribed Fosamax Plus and also taking cholecalciferol.
• Patient taking Aratac
and Cordarone at
the same time.
• Patient taking Celebrex sample provided by doctor
as well as the Celebrex
dispensed at the pharmacy.
• Patient taking OTC Nurofen as
well as prescribed Celebrex.
When Not to Use:
If the
drugs involved are not of the
same
therapeutic
class,
then
use “Drug Interaction (D2)”.
If the
patient is already
experiencing adverse effects due to using the two drugs together,
then
use “Toxicity, allergic reaction or adverse effect present (T1)”
Drug
interaction (D2)
When to Use:
When there are no obvious adverse
clinical effects of the
drug interaction between two medications that the patient is
taking or intending to take, but the
interaction is serious enough to check if
the doctor knows of it.
When the patient presents with an OTC request that could result in a major interaction if taken with their concurrent
therapy.
Examples of
when
to use:
• Patient commenced on tramadol who is already taking fluoxetine.
• Patient ceases amiodarone while
continuing on warfarin.
• Patient requests to purchase an over the
counter
antacid when taking doxycycline.
• Patient wishes to
use
St John’s Wort for depression, but is currently taking tramadol.
When Not to Use:
If the
interacting drug is of the same
therapeutic
class as part of the patient’s existing therapy,
then
use “Duplication
(D1)”.
If the
drug is contraindicated due to an existing
medical condition or previous adverse
reaction to
the medication, then use “Contraindication apparent (D6)”.
If the
patient is already
experiencing adverse effects due to using the two drugs together,
then
use “Toxicity, allergic reaction or adverse effect present (T1)”.
Wrong
drug (D3)
When to Use:
When the patient is taking a medication that has been incorrectly
prescribed (prescribing error) or incorrectly
dispensed
(dispensing error).
Examples of
when
to use:
• Doctor prescribes chlorpromazine 200mg bd but intended carbamazepine 200mg bd.
• Patient supplied with and taking Hydrea
2 m, labelled as Hydrene 2
m.
When Not to Use:
When a drug is discontinued or out of stock
on
a long-term
basis and the doctor is contacted for a change in therapy,
then
use “Other drug selection problem
(D0)”.
Incorrect strength (D4)
When to Use:
When the patient presents with a new prescription that has incorrect or no details about a drug’s strength that may
require
clarification from the
prescriber.
When
a drug chart or hospital discharge shows a strength that appears to
be incorrect.
Examples of
when
to use:
• Prescription presented for
‘Seretide
inhaler’ with no strength indicated.
• New prescription for diclofenac 50mg BD, when the patient was previously on 25mg BD
and
the doctor has not provided the
patient with reason for change.
• Locum doctor prescribes Karvea 150mg daily, but previous therapy was 300mg daily.
When Not to Use:
If the
patient presents a prescription for an old medication that has been superseded by a newer one that they
should be
taking, then use
“Other compliance
problem (C0)”.
Inappropriate dosage form (D5)
When to Use:
When the formulation of the
product is inappropriate or incorrect in
terms of the
intended use of the
product, including
incorrect
routes of administration.
Examples of
when
to use:
• Vancomycin oral capsules prescribed to treat systemic infection.
• Ear
drop product ordered or
supplied for an eye
problem.
• Directions state
an unattainable
dose
such as doxepin 5mg daily (only come as 10mg capsules).
When Not to Use:
If the
patient has a physical
problem with the
administration of the
dosage form as it is intended to be
used (eg. swallowing a particular form
of
the medication whole,
cannot appropriately insert suppositories,
arthritis limiting the
use
of an inhaler) or their difficulty
is related to a lack
of
understanding on how to use the dosage
form,
then
use “Difficulty using dosage form
(C5)”.
Contraindication apparent (D6)
When to Use:
When there is a contraindication or precaution to
that drug being used in a particular patient due to their medical
conditions, not their drug therapy.
When
a drug or drug group is prescribed for the patient to
which there has previously been a major adverse
reaction.
Examples of
when
to use:
• Augmentin Duo Forte prescription presented for a patient allergic to penicillin.
• Diclofenac prescription for
a patient with history of aspirin-induced asthma.
• Patient with Parkinson’s disease prescribed prochlorperazine.
• Doctor prescribes a
high dose thiazide in a
patient with a history of
gout.
• Doctor prescribes enalapril for a lady who is 7 months pregnant.
When Not to Use:
If the
drug is contraindicated due to existing drug therapy, then use “Drug interaction (D2)”.
If the
patient is already
experiencing toxicity or an allergic
reaction, then use “Toxicity, allergic
reaction or adverse effect present (T1)”.
If the
drug is felt to
be contraindicated due
to therapeutic
duplication,
use
“Duplication (D1)”.
No
indication apparent (D7)
When to Use:
When there is no clear apparent reason the
drug should be used.
Examples of
when
to use:
• Patient commenced omeprazole when they were
taking Celebrex
for a sore knee. Celebrex has been ceased, but
they are
still taking omeprazole.
• Patient using long-term steroid eye drops without a current indication.
When Not to Use:
If the
drug is felt to
be
unnecessary
due to therapeutic
duplication, use “Duplication (D1)”.
Other
drug selection problem (D0)
When to Use:
When the drug being used is out of date or has deteriorated in some
other way.
When
a drug is discontinued or out of stock on a long-term
basis and the doctor is contacted for a change in therapy.
When you believe a
more effective drug is available and you suggest it instead of the
current therapy.
Examples of
when
to use:
• Patient is using Anginine tablets that are
over
2 years old and/or have been stored incorrectly.
• Patient presents a
prescription for
trimethoprim for
a UTI which is out of stock for
another
3 weeks,
so
the doctor is contacted for an alternative antibiotic.
When Not to Use:
If another brand must be
substituted because the ordered brand cannot be used due
to a physical problem
related to the
patient taking the
drug,
then
use “Difficulty using dosage
form (C5)”.
Over or underdose prescribed
Problems relating to the prescribed dose or schedule of the drug
Prescribed dose too high (O1)
When to Use:
When the total daily
dose
of
a medication prescribed is too high for the
patient, either based on previous dosage or
reference
dose
ranges, including situations where
the dose that is prescribed is too high by unintentional error.
Includes the situation where
the dose is too high because
of
a particular parameter of the patient such as renal function weight, age
etc.
Examples of
when
to use:
• Patient is prescribed Diamicron MR 180mg in the morning (exceeds maximum recommenced dose of 120mg daily).
• 95 year
old
50kg women prescribed norfloxacin 400mg bd (dose
potentially too high due
to
renal impairment).
• Patient is prescribed dexamethasone
50mg daily (doctor was thinking of prednisolone dose).
• Patient prescribed spironolactone
100mg bd for heart failure.
When Not to Use:
If the
patient is taking too high a dose as a result of compliance
issues, then use
“Taking too much (C2)”.
If the
patient is already
experiencing toxicity symptoms as a result of a high dose,
then
use “Toxicity, allergic
reaction or
adverse effect present (T1)”.
Prescribed dose too low (O2)
When to Use:
When the dose
prescribed is either too low based on reference
dose
ranges or too low based on previous therapy.
This includes situations where the
dose
prescribed is too low by
unintentional error.
Examples of
when
to use:
• Patient with moderate vitamin D
deficiency (vitamin D 18 µmol/L)
prescribed Ostevit 1000 U
daily
(recommended dose
is 3000-5000 U daily for 2-3 months, then 1000 U daily).
• Prescription for
Singulair 4mg daily for an adult patient.
• A 25kg child is prescribed amoxycillin 125mg/5mL (4mL TDS) .
When Not to Use:
If the
actual dose per day
is correct, but the duration is too short,
then
use “Incorrect or unclear dosing instructions
(O3)”.
If the
patient is taking a low dose of a drug as a result of poor compliance, then use “Taking too little
(C1)”.
Incorrect or unclear dosing instructions (O3)
When to Use:
When the specified dosing time is not optimal.
When
the duration of use of the
product is too short or too long, including incorrect dose titrations.
When
the total dose of a medication is suitable,
but the
frequency
or
the dosage
schedule is inappropriate.
Examples of
when
to use:
• Simvastatin ordered as 40mg in the morning.
• Nystatin oral drops ordered only until symptoms resolve, not for the
additional 48 hours afterwards.
• Diamicron
MR prescribed as three times daily.
• Patient presents a new prescription for
lamotrigine 100mg BD with no instructions to increase slowly (dose
should start at 25mg/day for
2 weeks and increase by a maximum of 50-100mg every 1-2 wks; even lower starting dose if patient is already on other anticonvulsants).
When Not to Use:
If the
patient is not taking the appropriate
dose of a product as a result of a lack of understanding of the dosage regimen,
then
a compliance
related code
would be more appropriate.
Other
dose problem (O0)
When to Use:
Any
other dosing problems.
When Not to Use:
If the
patient is not taking the appropriate
dose of a product because of a lack of understanding of the dosage
regimen,
then a compliance related code would be
more
appropriate.
Compliance
Problems relating to the way the patient takes their medication
Taking too little (C1)
When to Use:
When the patient uses too little of a medication as a result of forgetfulness or lack of
understanding of the dosage
regimen prescribed.
When
the patient chooses to take
a medication PRN instead of on a regular basis.
When the patient chooses to
discontinue a medication
by
choice or for an illogical or irrational reason.
Examples of
when
to use:
• Patient using Transiderm-Nitro patches only every few days, not regularly.
• Patient not taking medication
because
he/she believes it will "stop working later
on" (e.g. analgesics).
• Patient taking metformin only when required rather than regularly.
• Patient fails to
persist with treatment for
a chronic disease
(e.g simvastatin for
hypercholesterolaemia,
Flixotide
for
asthma).
When Not to Use:
If the
underuse
is appropriate because
of
the resolution of symptoms or a condition,
then
use “No indication apparent
(D7)” and specify
that
the drug may
no
longer be required.
If the
patient has a physical problem
with the administration of the
dosage form resulting in
too
little being used (eg.
swallowing a particular form of the
medication whole, cannot appropriately
insert suppositories, arthritis limiting the use
of an inhaler) then use
“Difficulty using dosage
form
(C5)”.
Taking too much (C2)
When to Use:
When the patient uses too much of a medication as a result of forgetfulness or lack of
understanding of the dosage
regimen prescribed.
Examples of
when
to use:
• Patient presents requesting a
second Ventolin inhaler
11
days after the
previous one was provided.
• Patient was continuing to take 50mg daily of prednisolone
because
they had forgotten to
commence
a dose
reduction schedule as instructed by the doctor.
• Patient believes they have
forgotten a medication and takes a
second dose on the
same day.
When Not to Use:
If the
overuse
is due
to an appropriate
increase
in use
because of increased symptoms,
then
use “Condition undertreated
(U1)”.
If the
overuse
consists of inappropriately taking two different brands or forms of the same ingredient or drug class unknowingly, then use
“Duplication (D1)”.
If the
patient takes too much and experiences signs or symptoms of toxicity as a result, then use
“Toxicity, allergic
reaction or adverse
effect present (T1)”.
Erratic use of medication (C3)
When to Use:
When a patient is taking the medication on an erratic
basis, usually
due to poor memory. Includes the
situation where
the patient is likely
to require a Webster pack.
Examples of
when
to use:
• Patient presents for
their simvastatin prescription which you dispensed 3 days ago, but prior
to that it was dispensed 2 months ago.
When Not to Use:
If the
amount of medication
being taken can be
easily
quantified,
then
use “Taking too little
(C1)” or “Taking too much
(C2)”.
If the
patient is experiencing signs or symptoms of toxicity
as
a result of a compliance
issue, then use “Toxicity, allergic
reaction or adverse
effect present (T1)”.
Intentional drug misuse including OTCs (C4)
When to Use:
When there is suspected overuse
of
a particular,
potentially abused, product is intentional, including OTC items.
Includes
the situation where
the prescription appears to
be
a forgery.
Please reserve this
category for
known drugs
of
abuse.
Examples of
when
to use:
• Patient appears to be doctor shopping.
• Patient requests Mersyndol on several different days a week, when they know different pharmacists will be working.
• Patient returns for a repeat prescription for nitrazepam after 1 week, claiming she
dropped the previous supply down the toilet.
When Not to Use:
If the
overuse
is due
to an appropriate
increase
in use
because of increased symptoms,
then
use “Condition undertreated
(U1)”.
If the
patient is experiencing signs or symptoms of toxicity
as
a result of intentional drug misuse, then “Toxicity, allergic reaction or adverse effect present (T1)” may be
appropriate.
Difficulty using dosage form (C5)
When to Use:
When the patient lacks understanding on how to use the dosage
form.
When
the patient has a physical problem
with the administration of the dosage form
or
device as it is intended to
be
used (eg. swallowing a particular form of the
medication whole, cannot appropriately insert suppositories, arthritis limiting
the
use of an inhaler). Includes when a brand needs to be substituted to
improve the patient’s ability
to dose themselves.
Examples of
when
to use:
• Patient cannot swallow her
slow release diltiazem capsules.
• Patient with scoliosis cannot insert suppositories.
• Controlled release tablet ordered for
a patient who must crush all oral medications.
• Patient requests Pressin instead of Minipress as they are easier to
halve.
• Patient has poor
technique and is unable to use
their
eye
drops,
ear drops and/or inhalers appropriately.
When Not to Use:
If the
formulation of the product is inappropriate
or
incorrect in terms of the
intended use of the
product, such as an
incorrect route of administration, then use “Inappropriate
dosage
form
(D5)”.
Other
compliance problem
(C0)
When to Use:
When the patient wishes to
collect a repeat for a medication that has been ceased or superseded by a new medication.
When
a patient is stockpiling medications.
When
the compliance category cannot be
categorised elsewhere.
Examples of
when
to use:
• Patient wishes to
collect Coversyl from an old prescription when he has been taking Coversyl Plus for
the previous
three months.
• Patient unwilling to use mirtazapine after
reading the package insert.
When Not to Use:
If the
compliance issue
results in
two
drugs of the same therapeutic class being taken inadvertently, then use
“Duplication (D1)”.
If the
patient does not wish to take
the medication because
it is causing an adverse
event of some sort,
then
a toxicity or adverse effect category would be appropriate.
Undertreated
Problems relating to actual or potential conditions that require management or prevention
Condition undertreated (U1)
When to Use:
When the patient has a symptom or disease condition that is not being treated adequately.
Examples of
when
to use:
• Patient taking Hydrene and Coversyl for
high blood pressure, but blood pressure
continues to
be high.
• Patient taking metformin 1g BD
but has BSLs consistently over 10mmol/L.
When Not to Use:
If the
patient has a condition that is not currently being treated with any medication, then use “Condition untreated
(U2)”
If the
patient requires additional therapy
as
a preventative
strategy
(eg
potassium when on a loop diuretic), then use
“Preventive therapy
required (U3)”.
If the
patient takes too little
and suffers worsening of their condition as a result,
then
use “Taking too little (C1)”.
Condition untreated (U2)
When to Use:
When the patient has a symptom or disease condition that is not currently being treated.
Examples of
when
to use:
• Patient has had consistently high blood pressure
in the pharmacy over the
past few weeks and may require
antihypertensive treatment.
• Patient develops nausea
as part of a
viral illness and requires addition of antinauseant medication.
When Not to Use:
If the
patient has a condition that is currently being treated, but is not adequately, then use “Condition undertreated
(U1)”.
If the
patient requires additional therapy
as
a preventative
strategy
(eg
potassium when on a loop diuretic), then use
“Preventive therapy
required (U3)”.
If the
patient takes too little
and suffers worsening of their condition as a result,
then
use “Taking too little (C1)”.
Preventive therapy required (U3)
When to Use:
When the patient requires additional therapy to prevent a likely adverse
event as a result of the
patient’s therapy,
coexisting diseases or risk factors.
Not to be used if the
patient already
has the
condition.
Examples of
when
to use:
• Patient commences on morphine slow release without laxative
therapy.
• You suggest the
addition of antiplatelet
therapy in an elderly, obese, male patient with diabetes and
hypertension.
When Not to Use:
If the
patient already has treatment for a particular problem, but it is not effective enough, then use
“Condition undertreated (U1)”.
If the
patient already has a condition that is not currently
being treated with any medication, then use “Condition
untreated (U2)”.
Other
undertreated indication problem (U0)
When to Use:
When the patient has any
other problem relating to actual or potential conditions that you think requires management.
Monitoring
Problems relating to monitoring the efficacy or adverse effects of a drug
Laboratory monitoring (M1)
When to Use:
When, in the
absence of any adverse
effects, you believe that a laboratory
test is required (e.g.
potassium, creatinine,
white
cell count, INR).
This includes any laboratory
test that is not done within the
patient’s home,
pharmacy or doctor’s surgery, for example a BSL could be formally
tested in a laboratory or tested in the
home/pharmacy with a BSL monitor. When, in the
absence of any adverse
effects, you believe that drug level monitoring is required.
Examples of
when
to use:
• Patient recently increased frusemide
dose
from 40mg daily to 120mg daily without a change in potassium
replacement.
• Patient commenced on cholecalciferol and you recommend his vitamin D
levels be
checked after
3 months.
• Elderly woman on metformin
who has not had her
HbA1c checked for two years.
When Not to Use:
If you believe there are already adverse effects associated with the
medication in question, then use “Toxicity, allergic
reaction or adverse
effect present (T1)”,
and
specify the parameter to be
tested and the current signs and/or symptoms
(eg, patient with leg cramps, suggest magnesium
level).
If the
need
for laboratory monitoring occurs as a result of a newly
commenced drug,
then use “Drug interaction (D2)”
and the monitoring then becomes a recommendation, not the primary problem.
If the
test will be occurring within the patient’s home, pharmacy or doctor’s surgery,
then use
“Non-laboratory monitoring (M2)”.
Non-laboratory monitoring (M2)
When to Use:
When, in the
absence of any adverse
effects, you believe that non-laboratory
monitoring is required (eg BP,
BSL,
temperature, weight). In the future,
the self-monitoring of INR
at
home would also come under this category. Also covers the
situation where the
test is undertaken as a screening process.
Examples of
when
to use:
• A patient with heart failure
has an appropriate increase in his dose of frusemide and you advise
him to weigh himself each day for
the
next week.
• An elderly patient is starting a new antihypertensive and you advise
her to come to the pharmacy to have her
blood pressure
checked over the
next few days.
• You advise
a diabetic patient to regularly check his feet.
• You advise
a patient on warfarin to regularly check their stools for
blood.
When Not to Use:
If you believe there are already adverse effects associated with the
medication in question, then use “Toxicity, allergic
reaction or adverse effect present (T1)”, and specify the
parameter to be
tested and the current signs and/or symptoms.
If you recommend monitoring of a parameter (eg weight,
BSL ,heart
rate) as a result of another drug problem, then that recommendation should be recorded in the Recommendation code section. The type of problem
that
leads to this recommendation may vary.
Other
monitoring problem (M0)
When to Use:
When the patient has another problem related to
the monitoring of his drugs for either efficacy or adverse
effects.
When
the patient should be having monitoring done, but has problems attending the
laboratory, or paying for the
test or equipment needed.
Education or
Information
Where a patient requests further information about a drug or disease state
Patient requests drug information (E1)
When to Use:
When the patient has a reasonable
understanding of their condition, but requests further information about their
medication.
Examples of
when
to use:
• Patient requests information about alendronate and you provide a CMI.
When Not to Use:
If the
patient is starting a new prescription item and provision of a CMI
is a mandatory
requirement.
If the
patient requests information primarily about the disease
state,
rather than a drug, then use
“Patient requests
disease management advice (E2)”.
Patient requests disease management advice (E2)
When to Use:
When the primary
purpose
of
the interaction with the
patient was to
inform them
of
critical aspects of the management or
prevention of a disease or condition. This interaction could be
proactive or reactive
Examples of
when
to use:
• You counsel a
patient with heart failure about fluid restriction
• You provide
information about weight loss or smoking cessation for
a person who has cardiovascular disease.
• You provide weight management tips to a newly diagnosed diabetic
• You counsel a
postmenopausal woman about the benefits of
weight-bearing exercise
• You help a pregnant lady choose a suitable antihistamine
for
her allergy symptoms
When Not to Use:
If the
patient request information primarily regarding a drug,
then
use “Patient requests drug information (E1)”.
If the
counselling is part of “normal” duties, such as counselling a patient about their new medication.
Other
education or information problem (E0)
When to Use:
When another health care
worker (e.g. a doctor or another pharmacist) requests information. Also covers any other education or information related problem.
Not classifiable
Problems that cannot be classified under another category.
Clinical interventions that cannot be classified
under another category (N0)
When to Use:
Usually
all
prescriptions should be
classified under
another category, however the ‘N’ category is to
be used when a
pharmacist feels a clinical intervention does not belong elsewhere.
Please note
that
the intervention must still
be clinical,
not administrative.
When Not to Use:
If the
problem is
administrative,
it is not a clinical intervention and does not need to be recorded. For example;
- When a prescription is illegal due to state or Federal law
- When the prescription does not meet PBS requirements (i.e.
incorrect number of tablets or repeats)
- When an Authority prescription is not approved or incorrect
- When the drug is unavailable from the
manufacturer or is out of stock
temporarily
- When the prescriber is not authorised to prescribe
that
particular medication.
- When
the patient has problems getting to
pharmacy or collecting prescriptions.
Toxicity or Adverse reaction
Problems relating to the presence of signs or symptoms that may be attributed to a drug
Toxicity, allergic reaction or adverse effect present (T1)
When to Use:
When the patient has signs or symptoms that suggest toxicity, an allergic reaction or an adverse
effect. Also includes the
situation where
compliance issues have lead to symptoms of toxicity.
Examples of
when
to use:
• Patient has increased their
dose
of
tramadol and develops headache,
sweating and agitation.
• Promethazine and amitriptyline
together causing worsening of dry mouth.
• Patient prescribed Diamicron MR three
times daily and has significant hypoglycaemic symptoms.
• Patient intentionally misusing
medication presents with signs or
symptoms of toxicity.
• Patient taking warfarin develops an elevated INR after commencing metronidazole.
• Patient taking perindopril and frusemide, who commences diclofenac
and develops renal dysfunction.
• Patient taking metoprolol exhibits worsening asthma symptoms.
• Patient taking amoxycillin develops an itchy, red rash.
When Not to Use:
If the
patient does not have any
signs or symptoms of adverse
effects and you believe the
dose is too high, then use “Dose too high (O1)”.
If the
patient has an interacting drug present,
but
there are NO signs or symptoms of the
interaction causing an adverse
effect, then use “Drug interaction (D2)”.
Where the
patient has been prescribed interacting drugs but has not taken the
medications, then use “Drug interaction
(D2)”.
If there are no signs or symptoms of toxicity
or
allergic reaction, but there is a possibility one
could occur because
of
the patient’s medical conditions or medical history,
use
“Contraindication apparent (D6)”.
