3.2 Drug characteristics
In general, the underlying mantra of ‘first do no harm’ was seen as an important aspect of prescribing. For example, both doctors and pharmacists aimed to avoid harm by identifying side-effects or unwanted effects and were aware that polypharmacy could be detrimental.
Facilitator: “What are you seeking to achieve when you assess medication when you first see a patient?”“Basically - what they are taking and what they are supposed to be taking?” (Doctor A, 2017)“Are any of the medications causing the patient symptoms? Is there polypharmacy?” (Doctor B, 2017)“Are we worried about any side-effects?…the reason that the patient is here is because of the medications [that] can possibly [be] driving them.” (Doctor C, 2017)
Knowledge of national or local guidelines influenced prescribers’ ability to manage this as well as using them as justification for initiating prescribing. However, guidelines also limited individuals’ prescribing independence with doctors indicating that they were reluctant to change an existing medicine (i.e. one that the patient had been taking prior to admission) unless overt clinical harm had occurred, or prompted by a specific guideline regardless of patient benefit profile.
These decisions were further modified according to their perceived knowledge of the pharmacological group of the drug. There was a reluctance to stop potential ‘culprit’ medicines because of a lack of knowledge, either of the drug itself, or the original reason for prescribing it. For example, “well generally, how long have they been on it? …Let’s be honest, we don’t know how they work and also [I would be concerned about] the side effects of acute withdrawal…” (Doctor, 2016). “Yeah, and the exact rationale in terms of their use is not necessarily clear…”(Doctor, 2016). This appeared to apply particularly to medicines prescribed for psychiatric conditions. By contrast, participants accepted that they preferred to adjust familiar drugs with effects they believed were more predictable such as antihypertensive medications.