01Principles and purposeThe professional or clinical skill and the decisions it supports.
Safe prescribing is a diagnostic and systems task. The correct product can still harm when indication, identity, allergy, dose, route, organ function, interaction, duration or follow-up is wrong. Primary care adds repeat supply, multiple prescribers and transitions. The prescriber remains responsible for obtaining adequate information and ensuring that proposed treatment serves the patient’s needs.
Define the therapeutic objective before selecting a medicine. State whether the goal is symptom relief, cure, disease modification, secondary prevention or short-term risk reduction. Confirm non-drug options and the consequence of no treatment. Use shared decision making for reasonable alternatives and explain material benefits, harms, monitoring, practical burden and uncertainty.
Choose from current authoritative sources. The BNF summarises UK prescribing; the medicine’s SmPC gives licensed indications and product-specific regimen; NICE or professional guidance may recommend a class or off-label use. Verify formulation, strength, route, frequency, duration and stop point. Never transfer a regimen between products or indications from memory when the source is available.
Patient factors modify the regimen. Check age, weight when dose-relevant, pregnancy and breastfeeding, allergy, kidney and liver function, swallowing, cognition, frailty and pharmacogenomic result where applicable. Review interactions with prescriptions, over-the-counter products, alcohol, substances and complementary remedies. A normal old creatinine may not represent current renal function during dehydration or acute illness.
Medication history is best elicited non-judgementally. Ask what is taken on a typical day, what is missed or changed and why. Compare repeat list, dispensing information, hospital letters and containers. Distinguish intentional from unintentional non-adherence. Address adverse effects, beliefs, cost, supply, dexterity, literacy and schedule before adding treatment.
NICE describes structured medication review as a critical examination of medicines with the person to agree treatment, optimise impact, minimise medicine-related problems and reduce waste. Prioritise people with polypharmacy, high-risk medicines, transitions, frailty, adherence difficulty or suspected harm. Review each item and the regimen as a whole rather than seeking a crude medicine-count target.
For each medicine ask: What is the indication? Is it effective for a current goal? Is the dose and formulation suitable? What harm or interaction exists? Is required monitoring complete? Can the person use it? Is duration or review date clear? Is a simpler or non-drug option better? Does another clinician need to agree change? Document rationale, especially when deviating from a guideline.
Repeat prescribing needs controls. Align quantity and review dates where appropriate, but do not create excessive stock. Define high-risk monitoring and what happens when overdue. Review early requests, duplicate items, discontinued hospital medicines and medicines prescribed “as directed”. Changes should reach the pharmacy, care provider and patient promptly to prevent old supplies being taken.
Transitions are high-risk. Medicines reconciliation compares the most accurate pre-transition list with new orders, resolves discrepancies and communicates an updated list with reasons for changes. After discharge, identify newly started, stopped, dose-changed and time-limited items; clarify specialist monitoring and shared-care acceptance. Do not assume a letter’s presence means every change reached the patient or community pharmacy.
Deprescribing is a planned prescribing decision. Identify medicines with no current indication, limited benefit, unacceptable harm or excessive burden. Consider withdrawal and rebound; some medicines need gradual reduction. Agree sequence and monitoring, usually changing one medicine at a time when safe. Provide a restart or escalation plan where recurrence is possible and communicate to all suppliers.
Prescribing remotely requires the same adequate knowledge and suitable mode as face-to-face care. Verify identity, location when urgent, relevant history and records. Do not prescribe simply because a questionnaire generated a request. Arrange examination or tests when required. Controlled drugs, antimicrobial stewardship and high-risk medicines need their specific legal and clinical safeguards.
Suspected adverse reactions require care first: assess severity, stop or treat when indicated, and provide emergency action. Document drug, formulation, dose, timing, co-medication and reaction. Report eligible reactions through MHRA Yellow Card; reporting does not require proof of causation. Update allergy or adverse-reaction records precisely so intolerance is not mislabeled as anaphylaxis and true severe allergy is not lost.
Monitoring completes treatment. State baseline tests, response measure, toxicity measure and interval from the current guidance. Results must be reviewed, communicated and acted upon. Define who prescribes while waiting and who responds to non-attendance. A shared-care document supports responsibility only after the relevant clinicians and patient understand and accept it.
Audit prescribing with clinical context. Useful measures include valid indication, completed monitoring, reconciliation after discharge, patient understanding and resolved discrepancies. Crude reduction in items or cost may reward under-treatment. Review incidents and near misses for interface, software, labelling and communication causes, then test system changes.
Key points
- Before prescribing, confirm identity, indication, allergies, pregnancy potential, relevant organ function, current medicines and enough clinical information for the decision.
- Use the current BNF, SmPC and condition guideline for exact dose, route, frequency, duration, contraindications and monitoring; separate licensed product information from national recommendation.
- A structured medication review is a shared, critical examination of all medicines to agree treatment, optimise benefit, minimise problems and reduce waste.
- Reconcile what the patient actually takes with primary-care, hospital, pharmacy and specialist records after every transition.
- For each medicine record indication, effectiveness, adverse effects, adherence, interactions, monitoring, duration and who owns continuation.
- High-risk repeats need reliable test-and-result systems; an automatic repeat should not bypass overdue safety monitoring.
- Deprescribing requires evidence, consent, taper or contingency where relevant and follow-up for withdrawal, rebound or recurrence.
- Report suspected adverse drug reactions through the MHRA Yellow Card scheme while providing immediate clinical care and documenting the event.
02Situations and prioritiesThe context, relevant information and actions that matter most.
A repeat medicine without a current indication or intended outcome cannot be meaningfully reviewed for benefit.
Hospital, practice, pharmacy and patient lists differ after admission or specialist review and require active resolution.
Overdue safety tests or unreviewed results make automatic continuation potentially unsafe. Arrange urgent review by the responsible prescriber and an individual interim plan that also accounts for harm from interrupting treatment.
A new symptom caused by treatment is diagnosed as another condition and prompts an avoidable additional medicine.
A correct ingredient at the wrong strength, release form or route can create major underdose, overdose or administration failure.
Abrupt discontinuation of some long-term medicines can cause physiological withdrawal, rebound or disease recurrence.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Best possible medicines history - Why
- Establish actual current exposure and discrepancies.
- Interpretation and limitations
- Triangulate patient account, containers, repeat list, dispensing and clinical letters and resolve rather than merely list differences.
- 02
Indication-benefit map - Why
- Link each treatment to a current objective.
- Interpretation and limitations
- No clear link triggers record review and prescriber discussion; it is not by itself authority for abrupt cessation.
- 03
Safety and interaction screen - Why
- Identify allergy, organ-function, pregnancy and combination risks.
- Interpretation and limitations
- Use current medicine-specific sources and recent clinical context, not generic interaction flags alone.
- 04
Monitoring completion check - Why
- Confirm baseline and continuing safety requirements.
- Interpretation and limitations
- Verify the result was reviewed and acted upon; a test ordered or sampled is not a closed safety loop.
- 05
Use and understanding assessment - Why
- Determine whether the patient can and does implement the regimen.
- Interpretation and limitations
- Teach-back and demonstration identify misunderstanding, device difficulty and intentional choices requiring a different plan.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked case: discharge discrepanciesReconcile before repeatingA patient requests repeats after admission; the discharge list stops one medicine, halves another and adds a seven-day item, but old repeats remain active.+
- 1Confirm what the patient has actually taken since discharge, current symptoms and urgent harm; compare hospital list, pre-admission record, pharmacy supply and available results.
- 2For every discrepancy establish whether change was intentional, why, duration, monitoring and responsible clinician; contact the hospital team when the rationale or safety is unclear.
- 3Complete the final action by updating active repeats, issuing only verified necessary supply, documenting reasons and communicating the reconciled list to patient, pharmacy and relevant care providers.
- 4Verify understanding with teach-back, arrange medicine-specific monitoring and expiry of the time-limited item, and review for disease control, adverse effects and unresolved specialist responsibility.
02Structured medication reviewLink every item to value and safetyPolypharmacy, high-risk treatment, frailty or adherence difficulty creates medicine-related risk.+
- 1Elicit goals and actual use and reconcile the complete regimen.
- 2Assess indication, effectiveness, safety, interaction, burden, monitoring and continued need item by item and collectively.
- 3Agree changes, sequence, monitoring and communication with the patient and relevant prescribers.
03Suspected adverse reactionTreat, document and reportSymptoms begin after medicine exposure and a causal contribution is plausible.+
- 1Assess severity and provide urgent treatment or medicine withholding when clinically indicated.
- 2Document precise product, dose, timing, phenotype, co-medication and relevant tests and update allergy or reaction coding accurately.
- 3Report through MHRA Yellow Card when eligible and arrange follow-up without waiting for proof of causation.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Define response, toxicity and review timing when each medicine is started or changed.
- Track high-risk laboratory tests through review, communication and action.
- Reconcile after admission, discharge, specialist change and care-setting transfer.
- Review early repeats, duplicates, time-limited items and excessive stock.
- Monitor withdrawal, rebound and recurrence after deprescribing.
- Audit interface discrepancies and patient understanding, not only item count or cost.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
A repeat is a new decision
Authorising continued supply confirms that indication, safety and monitoring remain acceptable at that time.
Reconciliation is resolution
A list of discrepancies is incomplete until each difference is explained and the correct regimen is communicated.
Off-label is not ungoverned
Evidence, consent discussion, documentation and monitoring remain necessary when national guidance supports use outside a licence.
Allergy labels have consequences
Precise reaction phenotype and timing prevent both dangerous re-exposure and needless exclusion of useful medicines.
Fewer is not always safer
Appropriate polypharmacy can improve outcomes; the goal is value, usability and safety rather than a numerical ceiling.
07Common pitfallsFrequent interpretation and management errors.
- 01
Do not prescribe without a clear indication and intended outcome.
- 02
Do not copy a dose between formulations, routes or indications.
- 03
Do not infer current renal function from an old stable result during acute illness.
- 04
Do not renew high-risk treatment automatically with unresolved monitoring; arrange an individual interim prescribing decision, balancing toxicity against interruption or withdrawal risk.
- 05
Do not assume a discharge letter automatically updates pharmacy-held supplies.
- 06
Do not stop medicines with withdrawal potential abruptly.
- 07
Do not code every adverse effect as allergy or every allergy as intolerance.
- 08
Do not wait for certainty before reporting a suspected serious reaction.