Prescribing in palliative care can be highly complex. Some medication regularly used in a palliative care setting can cause considerable harm if not used appropriately. An audit of prescribing within in one 20 bedded adult in-patient unit demonstrated poor prescribing practice. On-going scrutiny of prescription charts on a weekly basis by the hospice pharmacist showed consistent areas of poor prescribing despite regular updates and prescribing teaching sessions.

Type of medical prescribing errors frequently identified included

• Illegible or unclear prescription with no signature

• Key elements of the prescription such as indication, route, frequency or maximum dose in 24 h missed

• Regular prescription written but no rescue medication prescribed when appropriate to do so such as with opioids

• No clear identification of possible risks and drug interactions

Type of medical prescribing errors frequently identified includedAs a result the in-patient unit drug chart was completely redesigned. A prescribing booklet was produced with sufficient administration boxes to cover the average 2 week admission. The booklet has separate sections for each of the key prescribing areas:

• Anti-coagulation prophylaxis and long term therapy

• Use of steroid medication including the co-prescribing of Non-steroidal anti-inflammatory (NSAIDs)

• Use of oral chemotherapy

• Opioid and opioid rotation

• Continuous subcutaneous infusions

Continued weekly scrutiny of prescribing and administration by the pharmacist has demonstrated that the prescribing booklet has improved all aspects of prescribing and administration of medication across the unit.

The new prescription chart has reduced the number of prescribing errors per session worked from a peak of over 4 per session to 1 or less per session. There is a variation between the more experienced senior doctors and the junior doctors who rotate through the unit, with the biggest fall in errors happening with the junior doctors.

Further work is on-going to refine the booklet.