GPs made the national newspapers at the start of this month but not for the best of reasons. The Prevalence and Causes of Prescribing Errors in General Practice (PRACTICE) study for the GMC showed mistakes in one in 20 of GP prescriptions and that one in 550 contained a serious error.
Here are 10 tips to help GPs cut down on those mistakes.
TIP 1. Use technology
Using the computer-based primary care record should be the norm.
Fortunately, few prescriptions need to be hand written, and ensuring prescriptions are issued and stored through this technology aids accuracy.
Although out-of-hours prescribing is also undertaken via IT, the system may not communicate directly with the main patient record.
I am reluctant to prescribe anything other than urgent medication when working out-of-hours. Even on visits I try to issue medication through the practice system or I enter the details as soon as practical if handwriting a prescription.
TIP 2. Listen to pharmacists' advice
Prescriptions on computer also prompt computer-aided advice. The plethora of potential interactions may be daunting but be wary of simply ignoring the pop-up advice screens.
I occasionally receive calls from pharmacists raising concerns about my prescriptions.
Pharmacists usually have relevant advice to offer and one suggestion in the PRACTICE study is a closer working relationship between pharmacists and GPs to aid safer prescribing.
TIP 3. Be allergy aware
Check and check again, especially when working out-of-hours. Computer-aided prescribing will highlight potential allergic reactions but only if a drug allergy has first been entered.
TIP 4. Beware secondary care
Does your practice have a clear pathway for entering repeat medications from discharge summaries and outpatient letters? If so, who does it? This was one of the potential danger areas highlighted by the PRACTICE study.
While someone other than a doctor may enter this data, someone with medical training seems safest. The potential for error is huge: discharge letters may be delayed for weeks; other medications may have been prescribed or other outpatient consultations may have taken place in the interim.
Consider your current system: are there pitfalls?
Does your practice have a clear pathway for entering repeat medications from discharge summaries and outpatient letters?
TIP 5. Monitor drugs
Inadequate monitoring or no monitoring at all was another area the study highlighted. Having clear protocols is essential, especially where there is shared care.
Clear responsibility helps to prevent errors that might occur if there is uncertainty over which team member is monitoring the medication.
TIP 6. Be ready to say no
It can be awkward to decline to issue medication, but if you feel unhappy or unsure, saying no may be in the patient's best interest.
If you are unfamiliar with the medication suggested by secondary care or a patient, or it is being used off the product licence in a way causing you concern, GMC guidance supports the decision to decline a prescription. Similarly, declining to prescribe when there are contraindications supports safer prescribing.
Explaining to patients that you need extra information to ensure safe prescribing can usually alleviate the situation.
TIP 7. Give clear instructions
The PRACTICE study highlighted the problems of putting 'take as directed' on prescriptions. Sometimes this is the only possible instruction - for example, when variable doses are needed - but always prescribe with clear instructions.
Reiterating the instructions verbally to the patient and/or carer also supports this - as does writing them down. Often when stopping a medication, I write the name down so patients can be sure which box to dispose of.
TIP 8. Check and double check
While this is particularly important for those at high risk, for example, the elderly and those on multiple medications, constantly rechecking supports safety. Having a nurse recheck an injection, both the drug and its expiry date, is good practice in personally administered drugs. This may not be possible on the rare occasions when you are alone, but I find going through the procedure of saying this aloud reinforces the check verbally.
The second check by community pharmacists is another safety net but is not available in dispensing practices. Many dispensing practices use technological support, such as barcode software or robotic dispensing, to prevent the most common problem, picking errors, where a visually similar but incorrect medicine is taken off the shelf and dispensed erroneously.
TIP 9. No more verbal prescriptions
Giving verbal prescriptions, usually over the phone to pharmacists, is fraught with danger.
With secure email, fax and so on, there can be few occasions when this is really necessary.
TIP 10. Have a clear review date policy
Repeat prescribing helps patients and practices. Review dates support patient monitoring and can be linked to the QOF. But how does your practice deal with requests for medicines after the expiry of the repeat medication review date?
There is no definitive answer beyond a clear practice policy allied to safety. Not reviewing patients puts them at risk and while some leeway helps, too much may allow unsafe prescribing. My practice has a cut-off point of two months.
- Dr Phipps is a GP in Lincolnshire
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