Medication errors can be of different types and the consequences may depend on the error made. For example, prescribing a drug which has the potential for interaction with other drugs the patient is taking, might risk new or more severe side effects. In other circumstances the impact of prescribing the wrong drug can simply be that the patient is not receiving the treatment that you intend, and their condition may deteriorate as a result.
Whilst there are checks in place on GP systems, these are not fail-safe and errors can still occur. If an error has been made you need to establish the scope and extent of the problem.
Establish the extent of the problem
Dealing with your patient’s clinical wellbeing must of course be the first step.
Some medication errors might mean that the patient must be contacted without delay. In other circumstances it might be helpful to consider the likely impact of a medication error and potential risks that the patient might need to be monitored for before the doctor speaks to the patient.
Having all the facts before you ring them and any additional information, for example, from a pharmacist, will put you in a better position to advise the patient without causing any unnecessary concern.
Additionally, is there a risk that other patients have been affected by the same medication error? If so, can those patients be identified?
For example, this might be a concern, with immunisation errors when it is discovered that there has been a cold chain failure. In this case, the affected vaccines should be isolated, clearly marked and kept in the cold chain so they are not administered to other patients until the issue has been investigated.
Sources of information
The impact of some medication errors may be well known, for others (for example, accidental use of medication beyond its expiry date) it may be helpful to speak to the drug manufacturer or, in the case of immunisations, Public Health England or the local NHS England Screening & Immunisation Team.
CCGs may also have a liaison pharmacist or prescribing advisor who may be able to help with such queries.
Having these discussions proactively may help put the doctor in the best position to provide further advice and to answer questions the patient might have. It also demonstrates to patients that the practice's investigation has been robust.
Inform the patient
Once the doctor has this information, the patient should be contacted to alert them to the problem, the likely repercussions and to offer a plan. Depending on the number of patients involved, and any urgent need for review, this may be done with a telephone call followed by a letter or just by letter, if appropriate. This will depend on the circumstances and the urgency of the situation.
The GMC is clear in Good Medical Practice that healthcare professionals must be open and honest with patients when something goes wrong that causes, or has the potential to cause, harm or distress. This means offering an apology, putting matters right if possible, and explaining fully and promptly what has happened and the likely effects.
Apologising meaningfully when things go wrong is vital for everyone involved in an incident. It is not an admission of legal liability for what has happened but an acknowledgement that an incident could have been handled better. It can also support learning and improve patient safety.
Put it right where possible
The urgency of the situation will depend on what the patient’s clinical status is and what the medication was for. For example, has the patient received an incorrect drug which could cause potential side effects, especially if it was prescribed at the wrong dose or have they been taking an appropriate medication but at a lower or higher dose than recommended?
In the case of vaccines, does the patient need a follow up vaccine to ensure they have adequate immunity? Does the patient need any additional monitoring, such as blood tests or a specialist assessment, in view of the error?
Reporting
If the patient has come to any harm due to the medication error, the practice should also consider if the threshold is met for it to be reported to the CQC or covered by the statutory duty of candour.
In addition, the NHS National Reporting and Learning System (NRLS), a central database of patient safety incident reports, encourages healthcare staff to report patient safety incidents whether they result in harm or not. More information is available here.
Investigate further and review systems
In the longer term, practices would be advised to carry out a formal significant event audit or root cause analysis of the incident and inform the patient or patients that they are doing so.
The practice could also offer to feedback the outcome of that review in due course, if the patient would like this.
Patients are often reassured by this, as it demonstrates that a practice is taking the matter seriously and is taking steps to reduce the chance of a recurrence. It will also reflect well on the practice should the matter be escalated.
Depending on the nature of the error, the learning outcomes will vary but may include staff training and engagement in appropriate professional development.
Whilst most patients will be satisfied by the way in which the matter is dealt with some may wish to make a formal complaint. If this is the case, the patient should be supported to do so and provided with a copy of the practice’s complaint procedure. Practices are encouraged to seek advice from their medical defence organisation when a medication error occurs and in responding to any subsequent complaint.
