Prescribing safety in primary care

Advice for GPs on how to avoid prescribing errors and improve monitoring of repeat prescriptions. By Dr Sally Higginbottom

Avoiding prescribing errors requires personal, practice and IT strategies
Avoiding prescribing errors requires personal, practice and IT strategies

Two research papers on prescribing safety were discussed in a recent RCGP Essential Knowledge Update module.

One was a large multi-method study on prescribing errors in general practice, carried out on behalf of the GMC.1 The other was an ethnographic study of repeat prescribing in four UK general practices.2

Prescribing errors

Prescribing errors are common, affecting 1-40% of prescriptions, depending on the definition used. An avoidable cause of harm, they are responsible for about a quarter of litigation claims.

The GMC paper uses the following definitions:

  • Prescribing errors occur when there is either an increased risk of harm, or decreased probability of effective treatment due to a prescribing decision or prescription-writing process.
  • Monitoring errors are a failure to monitor a medication in a way which would be considered acceptable in normal GP practice.

The study used a variety of methods, including systematic reviews, an assessment by a specially trained pharmacist of 1,777 patient records in 15 practices, root cause analysis of specific errors, focus group discussions and interviews with primary healthcare professionals.1

The authors found that nearly 5% of the 6,000 prescriptions assessed had a prescribing or monitoring error, but this was mostly due to incomplete information on the prescription (for example, a medication being prescribed 'as directed').

Only 0.18% (11 prescriptions) were associated with severe error and of these, nine were related to warfarin and two were patients prescribed a medication they were known to be allergic to. The seniority of the GP did not change the error rate.

Factors found to increase the risk of error included:

  • Increasing numbers of prescriptions for a patient.
  • Men, children and elderly patients.
  • Smaller practices (<10,000 patients).
  • Failure to reconcile medications when discharge summaries received.

Simvastatin, warfarin, ramipril and bendrofluazide together accounted for more than 60% of all monitoring errors, presumably because they are so frequently prescribed.

KEY QUESTIONS FOR PRACTICES
  • Do you have a process in place for warfarin prescribing which mandates checking the recent INR result? Is this clearly documented each time?
  • How are medication lists checked and updated when discharge summaries are received?
  • Is your practice formulary up to date, in use and easily accessible (ideally from the prescribing module of your clinical IT system)?
  • How does repeat prescribing work in your practice? Who does what? Are you happy to sign prescriptions on that basis?

Repeat prescriptions

This study was an ethnographic observation of repeat prescribing in four practices.2

The researchers spent about 50 days watching receptionists, administrative staff and doctors carrying out repeat prescribing. At each practice, they identified written protocols, verbal descriptions of how staff understood the process and observed reality, that is, how repeat prescribing actually happened.

The four practices differed considerably in their repeat prescribing processes. The practice ethos clearly affected how repeat prescribing happened. In one, there was an emphasis on personal relationships, continuity and informal knowledge sharing. At the other extreme, one practice had a business-oriented culture, with uniformity, standards and protocols being prized.

There were two particularly striking findings in this study. First, there were significant differences between what a practice's repeat prescribing policy said and what happened.

The authors discuss the model/reality gap between the assumptions built into the protocol and the messy, unpredictable work of real life. This challenges the idea that a problem is solved when a protocol is written.

Second, more than half of repeat requests were not straightforward. They were for medicines not on the repeat list, medicines listed by a different name or those requested 'too early' or 'too late'.

Reception and administration staff used a variety of strategies for this, including asking each other, using a formulary, keeping notebooks of useful information, asking passing doctors, electronic messaging to doctors and sticky notes on scrips.

My suspicion is that most doctors are unaware of all this 'informal'

work being done by support teams. As we sign the prescriptions (often without checking a patient's notes), it is vital that we understand what is happening in our practices.

What the studies highlight

Prescribing is a complicated task and avoiding error requires personal, practice-wide and IT strategies.

Monitoring of high-risk drugs (especially warfarin and methotrexate) is commonly a source of error.

Repeat prescribing is safest in a culture of open communication and discussion between administrative and clinical teams. Communication with specialists following hospital admission needs careful checking for medication changes.

  • Dr Higginbottom is a GP and EKU author for the RCGP

REFERENCES

1. Avery T, Barber N, Ghaleb M et al. Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study. www.gmc-uk.org/about/research/12996.asp

2. Singlehurst D, Greenhalgh T, Russell J et al. Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study. BMJ 2011; 343: d6788.

Resource

RCGP Essential Knowledge Update 10. www.elearning.rcgp.org.uk

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