How to reduce the risk of prescribing errors

In light of plans to increase scrutiny of GP prescribing and new guidance on prescribing between primary and secondary care, Dr Naeem Nazem from the MDDUS highlights common pitfalls and how GPs can minimise the risk of mistakes occurring.

Prescribing the right drug, in the right dose, to the right patient, is one of the most important responsibilities of any GP.

Last month, health and social care Jeremy Hunt announced a new system for tracing GP prescribing errors in England. The system will link GP prescribing data with hospital admissions data for the first time and enable the NHS to see if a wrong prescription 'was the likely cause of a patient being admitted to hospital'.

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The move follows a review commissioned by the Department of Health and Social Care (DHSC), which estimated that 66m potentially 'clinically significant’ medication errors occur each year in the NHS, 71% of which are in primary care. It also estimated that avoidable adverse drug reactions in primary care that lead to a hospital admission result in 627 deaths a year and that around half of these involve a GI bleed.

At MDDUS, we regularly encounter calls from members on issues surrounding medication errors. Prescribing errors contribute to around 13% of GP negligence claims reported to MDDUS each year. These are some examples of common prescribing pitfalls and steps GPs can take to minimise the risk of mistakes occurring.

Write legibly

If you are handwriting a prescription, take care to write clearly and legibly, preferably in capital letters using the generic name of the drug. This should help ensure the many people who subsequently review and process your prescription do not misinterpret your entry. 

Extra care should be taken when prescribing or dispensing medicines that could be confused with others because they sound or look alike. Some examples we have encountered in which patients have received an incorrect drug due to an illegible prescription include: carbamazepine vs carbimazole, chlorpromazine vs chlorpropamide and Losec™ vs Lasix™.

These cases perhaps demonstrate how the use of capital letters and generic names can act to minimise the risk of medication errors.

Check computer-generated scrips

As highlighted by Mr Hunt, the use of electronic prescribing can help to reduce the risk of medication errors. However, as most GPs will attest, computer systems are not without their own pitfalls. 

Many online prescribing systems use predictive text to assist GPs in prescribing. However, a simple oversight in the drug being predicted can lead to very serious errors. MDDUS encountered one case where a patient developed severe toxicity after being prescribed methotrexate instead of metoclopramide.The doctor had typed in ‘met’ and selected the wrong option from the drop-down menu.

As a practice, you may want to liaise with your software provider to see if there are additional safeguards they can put in place within your system to reduce the risk of such errors occurring. 

In its latest drug safety update, the Medicines and Healthcare products Regulatory Agency (MHRA) cited recent cases in which patients have received the wrong medicine due to confusion between similarly named or sounding brand or generic medications – some cases with fatal outcomes.

Examples include Clobazam (benzodiazepine) versus Clonazepam (antiepileptic drug), and Propranolol (beta blocker) versus Prednisolone (corticosteroid).

Check dosage and frequency

One source of dosing errors is between ‘mg’ and ‘mcg’. This often occurs at the time of re-writing a barely legible drug chart, or when instructions to prescribe a drug do not come with the units.

Avoid the abbreviation ‘µg’ which is often misread as ‘mg’. You could also try adding a space between each letter to make it clearer, for example writing ‘m g’, ‘m c g’ or even ‘micrograms’ instead.

Even when the correct drug has been prescribed, patients can come to harm if it is given at an inappropriate dose or frequency. We have encountered several cases in which a loading dose of digoxin was inadvertently continued as a maintenance dose.

Similarly, errors have occurred when bisphosphonates have been prescribed daily rather than weekly. You may think these errors would not occur in your clinical practice, but they can affect even the most conscientious of doctors.

Confirm route

Many patients require complex medical care, which may include the administration of drugs by different routes. It is important to include a route of administration for every drug you prescribe. This may be particularly important in palliative care.

Consider drug interactions

Some patients may have complex co-morbidities requiring numerous medications. Check patients’ existing medicines before prescribing anything new. Many software programs are able to alert you to possible drug interactions when prescribing new medicines.

As well as contraindications, consider whether the effects of one drug may be affected by the addition of another, or whether the combination may pose a greater risk of adverse effects. We have seen cases of patients on warfarin reaching dangerous levels of anticoagulation due to the addition of an interacting antibiotic.

Identify drug allergies

This is probably the simplest prescribing error to avoid. Always check that the allergy information has been completed before issuing a new prescription chart and, if not, check with the patient. We have encountered numerous cases in which patients have made complaints or sought compensation following an adverse reaction to a known drug allergy.

Prescribing medicines initiaited in secondary care

You should also ask colleagues to clarify the dosing regimen and indication for any drugs they ask you to prescribe with which you are unfamiliar. GPs are often asked to prescribe specialist medication by consultant colleagues and, sometimes, off-licence medication for certain conditions. MDDUS recommends that GPs only accept responsibility for continuing or initiating such prescriptions if they feel they are competent to do so.

NHS England has issued new guidance on the responsibility for prescribing between primary and secondary care. The guidance reiterates requirements that GPs receive a discharge summary including details of patients' diagnosis and medication within 24 hours of them leaving hospital.

It also says that hospitals should provide patients with enough medicine to last a minimum of seven days after discharge and seek GPs' agreement where they believe that shared ongoing care of a patient who has been treated in hospital is appropriate.

If a consultant colleague is seeking to delegate the prescribing of a medicine to a patient’s GP they must ensure the GP has the appropriate skills and experience to provide safe care, in line with GMC guidance on delegation in Good Medical Practice.

If you do not feel comfortable to commence or continue a prescription from secondary care you should raise your concerns with the relevant healthcare professional. It is then the responsibility of the doctor wanting to delegate care to ensure he or she does so appropriately.

Don’t be afraid to seek help

Remember you are not alone. As well as the national and local formularies, you should take advantage of the knowledge of those around you. The local pharmacist and your local medicines management team will be able to provide valuable advice on dosing regimens and possible drug interactions.

You can also contact your medical defence organisation if you have any concerns about a particular issue relating to prescribing. At MDDUS we regularly engage with and educate our members on identifying medico-legal risks and promoting safe practice.

  • Dr Nazem is a medical adviser at MDDUS

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