Prescribing pitfalls

A REPORT published in 2012 by the GMC yielded some startling statistics in regard to primary care prescribing. Researchers found that as many as one in 20 prescriptions written by GPs contains an error. In England alone, with 900 million items prescribed each year, that amounts to 45 million errors. Although most of these errors were classed as mild or moderate, around one in every 550 prescription items was found to contain a serious error – equating to 1.6 million potentially dangerous prescriptions per year across England.

These findings highlighted some areas of needed improvement and also set the scene for the publication in February 2013 of the GMC revised guidance – Good practice in prescribing and managing medicines and devices.

Certain prescribing errors are obviously more likely than others. In the GMC report the most common types of errors were incomplete information on the prescription, dose/strength errors, incorrect timing of doses and failure to arrange appropriate monitoring of prescribed drugs. The risk also increased according to the number of medicines a patient was taking (each additional medicine increased error risk by 16 per cent), patient age (children and over-75s were twice as likely to have an error) and the type of medicine prescribed. Another study published in 2007 found that just four classes of drug are associated with around half of preventable medication-related hospital admissions: antithrombotics (e.g. aspirin), anticoagulants (e.g. warfarin), NSAIDs and diuretics.

Prescribing errors feature commonly in MDDUS case files either as patient complaints or more serious legal claims of clinical negligence, or GMC actions against members. Prescribing is also a common subject in the many thousands of advice calls handled each year by MDDUS medico-legal advisers. Some of the issues can be complex but more often than not doctors and practices are caught out by “simple” errors – an incorrect dose, or prescribing the wrong antibiotic.

Below are some common pitfalls in prescribing encountered by our advisers – by no means complete or comprehensive but just a reminder of what to consider in your daily practice.

Missed or missing information

One common element in many MDDUS cases involving prescribing errors is missing or missed information from patient files. These often involve a failure to consider cautions and contraindications, such as a prescription of allopurinol in a patient with impaired renal function, or prescribing NSAIDs to a patient on warfarin. Even obvious errors such as prescribing penicillin-based antibiotics to patients with documented penicillin allergy occur with surprising regularity.

Good patient records with appropriate alerts in place are an obvious essential but doctors should also be extra vigilant when dealing with high-risk drugs in high-risk patients. Most practices today rely on hazard alerts in electronic record systems but this can pose a risk with high “signal-to-noise ratios” leading GPs to sometimes ignore vital alerts. However, they have been proven to reduce the number of prescribing errors.

Keeping up-to-date is also essential. The new GMC prescribing guidance states: “You must maintain and develop the knowledge and skills in pharmacology and therapeutics, as well as prescribing and medicines management, relevant to your role and prescribing practice.” Doctors are expected always to take account of new treatment guidance from bodies such as NICE and SIGN and updates and alerts from the MHRA – and an up-to-date copy of (or online access to ) the BNF is a must.

Repeat prescribing errors

GPs often do not check repeats as closely as one-off prescriptions – that’s just a fact of life. Faced with a pile of repeat prescriptions to sign it can be difficult to ensure you are giving each one careful attention though most will be routine. Yet errors involving repeat prescribing are sadly common in MDDUS files – a potent corticosteroid cream prescribed over many years leading to local atrophy and systemic steroid side-effects, or medication addiction due to long-term benzodiazepine or analgesic prescribing.

The GMC is clear on the matter: “You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate.”

Good practice systems for repeats can offer a safety net for this fundamental requirement. The GMC requires that procedures ensure:

• the right patient is issued with the correct prescription

• the correct dose is prescribed, particularly for patients whose dose varies during the course of treatment

• the patient’s condition is monitored, taking account of medicine usage and effects

• only staff who are competent to do so prepare repeat prescriptions for authorisation

• patients who need further examination or assessment are reviewed by an appropriate healthcare professional

• any changes to the patient’s medicines are critically reviewed and quickly incorporated into their record.

Monitoring patients is particularly important in high-risk patient groups, such as the elderly, those on multiple drugs and in cases of hepatic or renal impairment where drug metabolism and excretion may be reduced leading to drug toxicity. Patients who refuse to attend for follow-up are an understandable cause of concern for GPs and a source of calls to MDDUS, the question being: should treatment be stopped? There is no blanket answer to this – an assessment of each patient’s individual circumstances is required. It is a matter of balancing the risk of continuing to issue a repeat prescription without review or monitoring against the risk of stopping treatment. More expert clinical advice may be needed from an appropriate specialist before making the decision.

In and out of hospital

Errors are common at the primary/secondary care interface and often occur with prescription changes when patients are discharged from hospitals or are seen at out-patient clinics. These could be alterations in medication or dosage and it is important that this information is safely transcribed and checked by qualified clinical staff. The GMC states: “If you are the patient’s general practitioner, you should make sure that changes to the patient’s medicines (following hospital treatment, for example) are reviewed and quickly incorporated into the patient’s record. This will help to avoid patients receiving inappropriate repeat prescriptions and reduce the risk of adverse interaction.”

Shared care between primary and secondary also comes with risks to doctors and patients. It is important again to remember that you are responsible for any prescription you sign even if on the recommendation of a hospital specialist. The GMC advises that you must “satisfy yourself that the prescription is needed, appropriate for the patient and within the limits of your competence.” Hospital doctors are also similarly obligated to ensure GPs are provided with appropriate information about new or unfamiliar drugs and to answer any questions or otherwise assist in the care of the patient.

Self-prescribing

MDDUS has handled a number of cases where practitioners have been subject to fitness to practise proceedings for either self-prescribing or for prescribing to a family member or friend. Be aware that the GMC takes a very dim view of this and not just for drugs of misuse but also for doctors, say, prescribing their own BP medicine without seeing a GP who would be monitoring the treatment and keeping necessary records.

The GMC is clear that you must not prescribe a controlled medicine for yourself or someone close to you unless no other person with the legal right to prescribe is available to do so and the treatment is immediately necessary to save a life, avoid serious deterioration in health or alleviate otherwise uncontrollable pain or distress. Should it be necessary to prescribe for yourself or someone close you should make a clear record justifying your decision. With the widespread availability of OOH services in most of the UK, the need to prescribe for yourself or your family is likely to be rare These are just few of the pitfalls involved in prescribing. Should MDDUS members have any queries regarding a medico-legal or ethical aspect of prescribing our medical advisers are available to take your call on 0845 270 2034.

Article by Dr Mary Peddie, MDDUS medical adviser, and Jim Killgore, editor of Summons