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Scenarios

Prescription Check 1

By Femi Lana • July 25, 2024 • Last reviewed: 24/09/24 •

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Summary Intermediate

In this scenario, a patient comes to the hospital pharmacy to collect a prescription. The pharmacist should check the prescription and contact the prescriber if any errors are found to rectify the mistakes.

Please ensure that this scenario and mark scheme aligns with the most up-to-date guidelines from the UK NICE and the BNF when using it for your OSCE assessment.

You will need a student pharmacist and an actor for this OSCE station.

Revision Topics

Be aware, this may reveal any answers!

Crohn's disease

Student Instructions

You are working in a hospital outpatient pharmacy. A 27-year-old patient comes to collect their discharge prescription. You need to check the prescription and respond appropriately.

You do not contact the prescriber for this station. Discuss your prescription checking aloud. Do not worry about using medical jargon.

To do

You must perform a legal, accurate and clinical check on this prescription using the latest up-to-date guidance.

If necessary, state any changes you wish to make to the patient actor.

You have 8 minutes.
You have access to the BNF.

The prescription:

Actor Instructions

This may reveal scenario objectives!

You are Nadeen Kaur (Nuh-deen, Kar)

Opening statement: “Hi, I’ve just been discharged, would I be able to collect my new prescriptions today?”

Patient Information:
Provide this information when prompted.

Name: Nadeem Kaur
DOB: 23/02/1997
Address: 14 Honey Drive, Eldora Springs, XYZ 2ZW.
Past medical history:

“I was admitted 3 weeks ago for an acute flare-up of Crohn's disease. This led to severe diarrhoea, abdominal pain, and a fistula.”

Medication History:

“I previously took azathioprine 100mg, one tablet daily for maintenance of remission of Crohn’s but I couldn’t tolerate it.”
“I have been prescribed Methotrexate for maintenance alongside some vitamin.”

Allergies:

“None.”

If the pharmacist mentions waiting for a new prescription because of a low dose:
- "Can't I just take the lower dose for now and get the higher dose next time? I don't want to wait!"
Accept the student's response

Mark Scheme

Introduction

0 / 2

Introduce yourself and greet the patient professionally.

Confirm the patient’s identity - name and age.

Verification of Prescription Details:

0 / 5

Is the patient's name and address correct on the prescription

Is the medication (Methotrexate and folic acid) accurate?

Confirms indication for the prescription.

Methotrexate - maintenance of remission of severe Crohn's disease after previous treatment with azathioprine

Folic acid - Prevention of side effects

Are the dosing instructions (frequency and duration) correct?

Identification of Patient History:

0 / 4

Ask about the patient's past medical history

Confirms medication history including dose, frequency, indication, including any over-the-counter products and herbal remedies

Ask about any allergies.

Ask about the specific symptoms

Identification of Prescription Errors:

0 / 4

Correctly identifies any issues with the prescription.

Prescribed 400mcg of Folic acid rather than the indicated 5mg tablets.

Explain the issue to the patient using appropriate language.

You have only been prescribed 400mcg tablets of folic acid

The correct dose needed is 5mg tablets

Suggest an appropriate plan for the patient.

States that they will contact the prescriber to correct the prescription - or similar

For example: "I will contact your prescriber to amend this. I will dispense the methotrexate today, but you must return to collect the folic acid within the same week as starting the methotrexate. Once the prescription has been updated you will be able to collect the folic acid tablets.

Advice

0 / 2

States the importance of taking folic acid whilst on methotrexate to the patient

States side effects of folic acid or methotrexate, and when to seek additional medical advice

Any side effect listed in the BNF suitable under folic acid or methotrexate. For methotrexate - examples include diarrhoea, fatigue, anemia. Folic acid side effect examples may include decreased appetite, flatulance or nausea.

Communication:

0 / 4

Ensure that the patient comprehends the situation and the correction process.

Maintain professionalism throughout the consultation.

Conclude the conversation professionally, offering to assist with any further questions or concerns.

The student did not say anything that could harm the patient

This includes but is not limited to, providing incorrect information or medication, misdiagnosing conditions, neglecting to inquire about allergies, making incorrect referrals, or failing to act on red-flag symptoms.

Any criteria marked in red must be met to pass this station.

Referral Criteria

Referral Criteria for Methotrexate

A&E

Lips or tongue become swollen, difficulty breathing or struggling to swallow: Signs of allergic reaction.

Urgent GP Appointment

Oral ulcers present: Sign of bone marrow suppression, increasing likelihood of infection.
sore throat: Sign of bone marrow suppression, increasing likelihood of infection.
Unexplained rash: This could indicate a severe allergic reaction or drug-induced skin conditions, such as Stevens-Johnson syndrome or toxic epidermal necrolysis.
abnormal bruising: could be a sign of thrombocytopenia (a low platelet count) or bone marrow suppression.
Persistent diarrhoea: a sign of gastrointestinal toxicity, which could lead to severe dehydration and electrolyte imbalances.
Yellowing of skin or eyes, abdominal pain: May indicate liver toxicity.
Swollen hands or feet, and difficulty urinating: May indicate renal impairment.
Bleeding in gums, urine, vomit, bruising: Possible indicator for agranulocytosis.
New or increasing dyspnoea or dry cough: may indicate methotrexate-induced pneumonitis, a potentially serious lung condition.

References

· HSC Public Health Agency. (n.d.).Methotrexate Oral (Adult) Shared Care Guidelines. [PDF] Available at: https://ipnsm.hscni.net/download/19/shared-care-guidelines/1432/methotrexate-oral-adult.pdf [Accessed 20 Aug. 2024].
· National Health Service (NHS). (2023).Methotrexate. [online] Available at: https://www.nhs.uk/medicines/methotrexate [Accessed 20 Aug. 2024].
· National Institute for Health and Care Excellence (NICE). (2023).Methotrexate: BNF. [online] Available at: https://bnf.nice.org.uk/drugs/methotrexate/ [Accessed 20 Aug. 2024].
· Electronic Medicines Compendium (EMC). (2023).Methotrexate 2.5mg Tablets - Summary of Product Characteristics (SmPC). [online] Available at: https://www.medicines.org.uk/emc/product/5443/smpc#gref [Accessed 20 Aug. 2024].

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Referral Criteria for Methotrexate

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Referral Criteria for Methotrexate

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