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Reflections of an independent prescriber

Choosing my words carefully

Working in an acute medicine ward, I often encounter communication issues around how patients’ medicines are reviewed. Within my ward, we have identified certain processes with medicines being stopped temporarily on admission to hospital.

An example would be a patient who is admitted with low blood pressure and acute kidney injury caused by dehydration secondary to infection. A simple review of the medicines would allow one to consider whether to stop any nephrotoxic and antihypertensive agents until normal hydration and kidney function had been achieved. This is a scenario that hospital pharmacists would encounter on a regular basis. However, when the ward staff change shift or when a patient is transferred to a different ward, how should the need for review of blood pressure or renal function be communicated? This is just one clinical scenario in which the ward team would need to provide clear instructions.

Recently, I encountered a patient who was taking warfarin for a prosthetic valve. She had a high international normalised ratio and a minor bleed, which was reversed by Beriplex and vitamin K. The INR fell rapidly to 1.4 and her bleeding risk was minimised. It was important to ensure adequate thromboembolic protection until the warfarin could be stabilised. I prescribed warfarin (at a suitable dose) and enoxaparin, which will be reviewed once the INR had returned to within the therapeutic range.

I discussed this with nursing staff on the ward. Their understanding of the instruction was that the patient should be administered the enoxaparin regardless of her INR and it was the doctor’s role to review the medicines. Clearly using the word “review” had not sufficiently expressed what I expected to occur.

I had fallen into the trap of assuming that everyone understood the plan. In my role on the ward I need to work as part of a multidisciplinary team that contributes to patients’ treatment plan. Communication is key to ensure that care is delivered in a co-ordinated manner.

Reflecting on this situation has led me to reconsider how I phrase much of the written and verbal information I provide to colleagues. I try to ensure that my intentions are clear at all times. For instance, I would now write “please administer warfarin as prescribed, check INR in 48 hours and discontinue the enoxaparin once the INR has reached a specific level”. 

The phrase “please review” is meaningless without context and, as prescribing pharmacists, we need to be clear about our intentions for patients continuing treatment.

Citation: Clinical Pharmacist DOI: 10.1211/CP.2014.20065548

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