What should I do if I don't feel comfortable prescribing a medication to a patient with a complex medical history, multiple medications, or a condition requiring careful management?

When You Don't Feel Comfortable Prescribing a Medication

Do not take over prescribing responsibility for medications you are uncomfortable with until you have conducted a thorough medication reconciliation, reviewed complete medical records, and obtained adequate monitoring data—if these cannot be obtained, it is legitimate and appropriate to refuse the prescription. 1

Immediate Actions to Take

Document Your Concerns Specifically

• Identify exactly what makes you uncomfortable: lack of medical records, absence of recent monitoring data for high-risk medications, inability to obtain reliable medication history, or unclear indication for the medication 1
• Document in the medical record that you cannot safely assume prescribing responsibility without adequate information 1

Request Essential Information Before Prescribing

• Obtain complete medication history including all prescription medications, over-the-counter drugs, herbal remedies, and alternative treatments 1
• Review drug allergies with specific details: dose, reaction type, temporal relationship, and susceptibility factors 1
• Access current medical diagnoses and active problems to understand the indication for each medication 1
• Obtain recent laboratory investigations relevant to medication monitoring (especially for anticoagulants, antidiabetics, antiarrhythmics) 1
• Review previous prescriber's treatment rationale and any documented medication adjustments 1

High-Risk Medications Requiring Extra Scrutiny

Never assume prescribing responsibility for these without adequate documentation:

• Anticoagulants (especially warfarin) due to increased error rates 1
• Insulin and other antidiabetic agents 1
• Amiodarone and other antiarrhythmics 1
• Central nervous system depressants 1
• Benzodiazepines (high-risk with significant potential for harm, particularly with chronic use) 2
• Medications that prolong QT interval (require baseline ECG) 2

Legitimate Reasons to Refuse Prescribing

You are justified in refusing when:

• Adequate medical records are not available for review 1
• The patient cannot provide a reliable medication history and no collateral sources exist 1
• High-risk medications are prescribed without recent monitoring data 1
• Multiple prescribers have created duplications and interactions that you cannot safely untangle without comprehensive records 1

Alternative Solutions to Outright Refusal

Involve Other Healthcare Professionals

• Request pharmacist involvement to obtain better medication histories and reduce medication error rates 1
• Pharmacist-led medication reconciliation can uncover drug therapy problems and improve prescriber confidence 3, 4

Delay Prescribing Until Safe

• Schedule an initial visit specifically for medication review before assuming prescribing responsibility 1
• Obtain records from the previous prescriber before the patient runs out of medication 1
• Provide only a short-term bridge prescription (7-14 days) while you gather necessary information 1

Conduct Systematic Medication Assessment

• Match each of the patient's conditions with their medications to identify potentially inappropriate medications 5
• Use validated tools: Beers criteria, STOPP/START criteria, or Medication Appropriateness Index for older adults 5
• Assess for drug-drug interactions, particularly in patients with polypharmacy (67% of medication histories contain at least one error, with 22% having potential for significant harm) 1

Special Considerations for Complex Cases

Older Adults with Polypharmacy

• These patients are more susceptible to medication errors and adverse effects 1
• Approximately 30-75% do not take medications as prescribed, and 33-69% of drug-related hospital admissions are attributable to non-adherence 5
• Consider immediate comprehensive medication reconciliation with systematic deprescribing 6

Patients with Multiple Prescribers

• Multiple prescribers dramatically increase risk of duplications and interactions 1
• Create a plan of action for any unresolved discrepancies and document it 1
• Share the updated medication list with the patient and obtain permission to communicate with other healthcare providers 1

Critical Pitfalls to Avoid

Never do these when uncomfortable with prescribing:

• Do not automatically accede to patient drug requests without proper assessment 7
• Do not start treatment with more than one new drug at a time 8
• Do not abruptly discontinue benzodiazepines, beta-blockers, or clonidine due to withdrawal risks 6, 2
• Do not assume all medications are necessary—44% of patients at hospital discharge receive at least one potentially inappropriate medication 5

When You Must Prescribe Despite Discomfort

If you cannot refuse and must prescribe, implement these safeguards:

• Provide only the minimum quantity needed until you can conduct proper review (7-14 day supply) 1
• Schedule urgent follow-up within 2-4 weeks for comprehensive medication review 6
• Establish specific monitoring plan: blood pressure for antihypertensives, renal function for nephrotoxic drugs, ECG for QT-prolonging medications 6, 2
• Give clear written and verbal instructions for each medication with specific indication 5
• Educate the patient about potential adverse effects and instruct them to report any new symptoms immediately 8, 7