How to prescribe safely as a GP

Simple measures can be put in place to avoid prescribing errors, says Dr Marika Davies.

The doctor signing a prescription takes full responsibility for it (Photo: JH Lancy)
The doctor signing a prescription takes full responsibility for it (Photo: JH Lancy)

A study on GP prescribing, carried out by the GMC, found that about one in eight patients had been exposed to a prescribing or monitoring error.1

Although the vast majority of prescriptions written by GPs were appropriate and effectively monitored, about one in 20 prescriptions contained a mild or moderate error, with about one in 550 containing a serious error. So are there risks to patients and how can these be reduced?

TOP PRESCRIBING TIPS

Review the procedures in place at your practice for repeat prescribing, medication monitoring, medication reviews and communication with secondary care.

  • Ensure that all staff are formally trained in the prescribing safety features on the computer systems used in your practice.
  • Remember that the doctor signing a prescription takes full responsibility for it, even if it is a repeat prescription, or a prescription they are asked to issue by a specialist or a nurse.
  • Familiarise yourself with the GMC's Good practice in prescribing medicines - guidance for doctors, 2008.
  • Be familiar with local formularies, guidelines and protocols, and liaise with the PCT prescribing adviser or pharmacist where you have any queries.
  • Conduct significant event audits where appropriate and report any serious errors that may occur to the National Reporting and Learning System.6

Monitoring and repeats

Regular monitoring is an essential part of the care of patients who are prescribed certain medications.

A patient on warfarin who fails to attend for INR blood tests is a scenario familiar to many GPs, and the Medical Protection Society (MPS) is often asked by doctors whether they should continue prescribing in these cases. This is a matter of clinical judgment and what you consider to be in your patient's best interests, based on careful consideration of the risks and benefits of continuing to prescribe. You should stress the importance of monitoring to the patient and carefully document the advice you have given.

Most doctors will also be familiar with the stack of repeat prescriptions waiting to be signed between clinic and home visits, but you should not be tempted to rush this important task.

Your practice should have a good repeat prescribing policy in place2 and time should be set aside for it, with the notes available to the doctor (ideally the GP who knows the patient best) who is signing the repeat prescriptions.

The prescriber is responsible for ensuring that the prescription is appropriate for that patient and that they have been reviewed where necessary.

Children and the elderly

The GMC study found that older people and those aged up to 14 years were at higher risk of experiencing a medication error.

Doses for children should always be calculated with care, and you should refer to the BNF for Children. Good communication with parents can be assisted by using the Medicines for Children leaflets published by the Royal College of Paediatrics and Child Health.3

The elderly are at increased risk of drug interactions due to the higher number of medications they may be taking for multiple conditions.

They may also need more help in understanding the regimen of drugs they have been prescribed and the importance of taking these regularly. Frequent review of these patients, especially when you are issuing repeat prescriptions, is essential.

Liaison with secondary care

Good communication with secondary care is vital in the provision of safe patient care.

When making a referral, all relevant clinical information, including an accurate drug history and any known drug allergies or adverse reactions, should be included.

Likewise, information received from secondary care in clinic letters or discharge summaries should be carefully recorded.

GPs may be asked to continue to prescribe medications that have been started in secondary care, and they should be satisfied that they have sufficient information from the specialist about the drug, as well as a clear agreement about who will carry out any monitoring that might be required.

Simple errors

Computerised prescribing has reduced the number of medication errors, but simple mistakes can still occur and can have serious consequences for the patient.

This most commonly arises when the wrong drug or dose is chosen from a drop-down menu, so be alert to this when prescribing and check the printed prescription before it is handed to the patient. If writing a prescription by hand, for example during a home visit, you must ensure that it is legible, signed and dated, and states the patient's full name and address, the name of the drug in block capitals and clear instructions for the dosage, the frequency and the method of administration.

Interruptions to clinical work were identified by GPs in the GMC study as a cause for concern. The report recommended that practices should develop strategies to minimise the frequency of prescribers being interrupted while carrying out their clinical work.

Communicate with patients

Do not assume that your patient understands the prescription they have been given. In one case, a patient with asthma exacerbated by his cat was spraying his pet with an inhaler to try to alleviate his symptoms.

You should be satisfied that the dosage has been clearly recorded and that the patient understands how to take the medicine and the need for follow-up or monitoring where this is relevant.

Some patients can be quite insistent when asking doctors to prescribe medication for them that the doctor may not consider to be appropriate.

In considering these requests, it is helpful to bear in mind GMC guidance, which says: 'in providing care, you must prescribe drugs or treatment, including repeat prescriptions, only when you ... are satisfied that the drugs or treatment serve the patient's needs'.4

New patients registering to join your practice may come with a long list of medications they are already being prescribed. These should not be simply added to the patient's prescription list by practice staff. An appropriate new patient review should be carried out.

Conclusion

More than 85% of practices undergoing clinical risk self-assessment by MPS in 2011 identified prescribing as a key risk.5 The pressures of general practice can make finding time to address these concerns challenging. Keep up-to-date by undertaking relevant CPD and reviewing patient safety systems to reduce the risks involved in prescribing to patients.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

  • Dr Davies is a medico-legal adviser at the Medical Protection Society
CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Read the GMC's Good practice in prescribing medicines - guidance for doctors, 2008, to ensure you incorporate it into daily practice.
  • Review the procedures in place at your practice for repeat prescribing, medication monitoring, medication reviews and communication with secondary care, to ensure that they are all fit for purpose.
  • Keep up-to-date with the latest developments in prescribing by attending a relevant CPD session.

References

1. Avery T, Barber N, Ghaleb M et al. Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study. 2012

2. Haynes K, Thomas M (eds). Clinical risk management in primary care. London, Radcliffe, 2005.

3. RCPCH. Medicines for children

4. GMC. Good practice in prescribing medicines - guidance for doctors, 2008.

5. MPS. Clinical risk self assessment results from more than 140 GP practices in 2011.

6. NHS. Patient safety

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