May 20, 2022

E-prescribing systems should consider patient weight for oral paracetamol supply, report concludes

Electronic prescribing and medication administration (ePMA) systems should include prompts to document a patient’s weight when dispensing oral paracetamol, a report from the Safety of Care Investigations Directorate concluded. of health (HSIB).

The report, published on February 24, 2022, investigated the prescription of oral paracetamol in hospitalized adult patients in England who, on admission to hospital, have a low body weight of less than 50 kg.

The HSIB investigation was prompted by the death of an 83-year-old low body weight patient admitted to hospital on January 8, 2020 after a fall.

While there, the patient was prescribed 1 g of paracetamol orally four times a day, but eventually developed multi-organ failure due to sepsis, as well as paracetamol-induced liver toxicity, the report from a coroner later concluding that his “prescription of paracetamol was higher than it should have been, and that played a part in his death”.

The HSIB found that the patient’s weight had dropped to 39.7kg after 20 days of hospitalization and, although this was noted on her medication chart, ‘investigation could not identify’ who had weighed the patient.

A member of the pharmacy team had reviewed the patient’s medication chart on January 31, 2020, noted the low body weight “and requested that her dose of low molecular weight heparin (a drug to reduce the risk of formation blood clots) be reduced” but did not request a change in the paracetamol dose, the report said.

Following the patient incident, the hospital trust told the HSIB that it had requested an in-app alert for the new ePMA system to “notify the prescriber if a patient’s body weight is below 50kg and that he was prescribed paracetamol more than 500 mg four times a day”.

In response, the HSIB recommended in its report that this be looked at more broadly, saying that “ePMA systems may benefit from including an alert for oral paracetamol that prompts documentation of a patient’s weight and take into account the risk of liver toxicity when their weight is less than 50 kg”.

He further suggested that it could be “beneficial if the evidence on oral paracetamol and low body weight is reviewed by relevant national bodies to reach consensus and agree on standardized prescribing guidelines”.

According to the report, advice on prescribing oral paracetamol in patients with low body weight differs between UK National Form and summaries of clinical knowledge from the National Institute for Health and Care Excellence.

In a statement released alongside the report, the HSIB said its investigation “has identified that while oral paracetamol toxicity is a known patient safety issue in the healthcare service, it may be under-recognized, and more evidence are necessary to fully understand the relationship with the lower body”. mass”.

“There is also limited literature on the broader systemic factors that impede the safe prescribing of paracetamol to low body weight adults, which could spur national learning and insight.”

Nina Barnett, consultant pharmacist in elderly care at the London North West Healthcare NHS Trust, said that “elderly people make up a significant percentage of hospital patients”.

“The importance of low body weight on dose and frequency of paracetamol in the elderly may not be as well recognized by clinicians as other drugs that require dose/frequency modification based on body weight.

“It would be helpful to raise awareness of this important issue, both with all clinicians and with the public who use paracetamol as an over-the-counter medication, to reduce potential harm,” she said.

Emma Davies, Advanced Pharmacy Practitioner in Pain Management at Abertawe Bro Morgannwg University Health Board, said: “There is not a lot of literature on reducing the dose of oral paracetamol and I think many assume that the alleged low oral bioavailability makes it less risky.

“In fact, the bioavailability is higher than many assume and the risks of oral administration are about the same, especially in the most sensitive people. [such as those with] low weight and elderly and frail patients.

“It’s important to note that paracetamol isn’t even as effective for many of the conditions it’s prescribed for long-term…so there are plenty of reasons to revisit it and cut it down or stop taking it. ‘use where it is not indicated or if the risks are too high.

Alice Oborne, Head of ePMA and Medicine Safety at Guy’s and St Thomas’ NHS Foundation Trust, said: ‘The uncertainty of risk for oral paracetamol is illustrated by the conflicting national resources and deserves further consideration. , although gathering more information about the risks may prove difficult. Risk factors for low body weight and malnutrition may not be independent variables.

“A caveat to restricting oral paracetamol is the possibility that patients will not receive an adequate (currently permitted) dose and their pain will not be controlled, leading to the prescription of opioids or non-prescription anti-inflammatories. steroids, which have their own drawbacks.”

Keely Galloway, National Investigator at HSIB, said the report is “a starting point for national bodies to make improvements, ensuring low body weight patients can be safely cared for in hospitals across England. “.