Drug-chart review, dose calculations and ADR detection

Why this matters on day one

The commonest useful thing you can do on a ward round is notice that a drug is causing the symptom being investigated. Nobody else on the team is looking at the chart line by line, and the PSA tests exactly this.

The sequence

1. 1Read it systematically. Allergies first. Then regular, then once-only, then as-required, then infusions, then the anticoagulant and insulin charts, which live separately and get forgotten.
2. 2Ask of every drug. Is there still an indication? Is the dose right for this renal function and weight? Is it duplicated (two NSAIDs, two sedatives, a beta-blocker plus a rate-limiting calcium-channel blocker)? Is there an interaction? Does it need monitoring, and has that been done?
3. 3Ask what is missing. VTE prophylaxis, aperients with opioids, gastroprotection with steroids or NSAIDs in the at-risk, bone protection with long-term steroids, and the time-critical drugs the patient takes at home.
4. 4Suspect an ADR. Any new symptom after a new drug. Confusion after anticholinergics or opioids. AKI after an ACE inhibitor, NSAID or diuretic. Hyponatraemia after a thiazide or SSRI. Falls after antihypertensives or sedatives. Bradycardia after a beta-blocker or digoxin. Rash after an antibiotic.
5. 5Act and report. Stop or change the drug, document your reasoning, tell the patient, and report a suspected adverse reaction through the Yellow Card scheme. Reporting is part of the job, not an optional extra.

What goes wrong

• Investigating a symptom thoroughly while its cause sits on the drug chart.
• Continuing a chart on admission without asking whether every drug is still appropriate for an acutely unwell inpatient.
• Forgetting the anticholinergic burden in the frail — it accumulates across several innocuous-looking drugs.
• Doing a calculation in your head. Write it down, and have it checked when it matters.