Red alert

DESIGNERS of primary care systems are continually introducing new ways to support GPs and other clinicians in making correct diagnostic, treatment and prescribing decisions.

Many involve digital alerts to support safe clinical decisions as part of remote monitoring device feedback systems or automated triage. Pop-up warnings may also appear when prescribing new drugs for a patient with a known allergy, current prescription or a condition for which a proposed medicine is contraindicated.

Such innovations are designed to assist GPs – and improve patient safety – but the result can sometimes be "information overload" in busy practices. Here we will examine risks associated with prescribing alerts.

A General Medical Council-funded study reported in 2012 that around one in 13 prescribing errors are associated with contraindications or hazardous drug interactions and this is continually replicated in MDDUS’ own ongoing analysis of prescribing-related negligence claims.

As a GP you will be confronted with multiple warnings from patient systems about drug interactions – some of them regarding potentially harmful combinations – each time you initiate a new medication. Clinical judgement is required to act upon, override or ignore these alerts. In some situations a patient may have competing comorbidities and there will be no alternative to prescribing a medicine which is contraindicated, in which case you will take note of the alert, prescribe the medicine (having explained the risks) and monitor the patient closely for adverse effects.

Certainly it is most logical for a clinician to take notice and act on alerts within the system at the point of prescribing. However, many GPs admit to feelings of "alert fatigue" . This is defined as "the mental state that is the result of too many alerts consuming time and mental energy, which can cause important alerts to be ignored along with clinically unimportant ones". GPs often report that reading and responding to these can be a challenge – particularly as they can often be irrelevant or redundant. Consider the pop-up "warning, drug with similar name" that offers no indication as to what it might be, or the alert urging doctors to "be cautious in patients under 18" despite the patient in question being aged 60.

A 2013 University of Edinburgh study found that GPs acted on only two per cent of computer prescribing alerts and, while improvements have been made, they are still largely considered more intrusive than helpful. Evidence suggests that each alert takes between seven and 14 seconds to process so it’s easy to see how an underpressure GP whose experience of the alerts has been mostly unhelpful will want to pass through them (perhaps too) quickly.

So how can you achieve safe practice and avoid missing a dangerous drug-drug combination?

The GMC is clear that doctors "must make good use of the resources available" and utilising a combination of resources is often advisable when prescribing new medicines. Although referring to the British National Formulary (BNF) and BNF for Children (BNFC) can take more time, the GMC is clear that you "must be familiar with the guidance".

In addition the GMC advises doctors who are unsure about interactions or other aspects of prescribing and medicines management to seek advice from experienced colleagues including pharmacists, prescribing advisers and clinical pharmacologists. As a GPST, your trainer or fellow practice GPs will be a useful resource, and can at least point you in the right direction where more specialist advice is required.

Up-to-date patient histories, accurate clinical coding and full patient prescribing records are crucial to ensure the relevance of system alerts. Practices must have robust recording processes in place to make sure alerts are raised appropriately, e.g. where a doctor tries to prescribe a beta-blocker for an asthmatic patient.

Documenting hospital-prescribed medicines (e.g. chemotherapy) or over-thecounter medications taken by patients (e.g. antihistamines or low-dose aspirin) in the medical record will avoid serious interactions being missed.

On this, GMC guidance states that: "You must check that the care or treatment you provide for each patient is compatible with any other treatments the patient is receiving". No system is perfect, so it is important to also ask the patient if they are taking any other medicines.

When prescribing a drug which is contraindicated, be careful to note that you have fully informed the patient of this – including any red flags – and detail what (if any) monitoring will be required. It shouldn’t be a surprise to the patient when they are contacted by the team to come in for a blood test or provide a specimen. Practices should have flexible but robust systems to monitor these patients, with alerts generated for those who default from review.

On a final note, it is less common now for GPs to delegate to non-clinical staff the task of adding new drugs to the records and certainly this is something to be avoided. Administrative staff are also likely to override alerts as they will assume you have taken these into consideration before deciding to prescribe. In conclusion, alerts can be frustrating for you as a GP, particularly as you adjust to using new systems, but they at least offer an opportunity to reduce clinical risk.

Liz Price is senior risk adviser at MDDUS