Clinical Intervention (Prescription Intervention)

 

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)”.