Prescribing Errors in General
Practice
The PRACtICe Study (2012) GMC
Investigating Prevalence and Causes
Definition
•
“A prescribing error occurs when, as a result of a
prescribing decision or the prescription-writing process,
there is an unintentional, significant reduction in the
probability of treatment being timely or effective, or
increase in the risk of harm when compared to
generally accepted practice”
Methods
•
Systematic Review
•
Retrospective review of (2%) sample of prescriptions
from 15 practices over 12 months
•
Interviews with prescribers for 70 potential errors
•
15 root cause analyses
•
6 focus groups
Results
•
>6000 items for nearly 1800 patients
•
prescribing / monitoring errors detected for 1 in 8
patients or 1 in 20 prescriptions
•
1 in 550 items severe error
Factors associated with an increased risk of
error
•
male patient
•
aged <15 or >64
•
increased number of items prescribed
•
musculoskeletal, immunosupression & malignancy,
skin, eye, ENT, cardiovascular disease, infections
•
smaller practices
Factors not associated with an increased risk
of error
•
grade of GP
•
acute or repeat prescription
Commonest Errors
•
incomplete information on the prescription (30%)
•
dose/strength errors (17.8%)
•
incorrect timing of doses (10.5%)
•
failure to request monitoring (69.1%)
Medicines Reconciliation
•
97% of hospital discharge prescriptions contained an
alteration from admission drugs
•
10% of these involved a change in dose (none
highlighted)
•
34% of discharge medications were ‘new’ (only 8%
highlighted)
•
discrepancies occurred in 42% of subsequent GP
prescriptions
Causes of Error
•
The Prescriber
•
The Patient
•
The Team
•
The Working Environment
•
The Task
•
The Computer System
•
The Primary Secondary Care Interface
Causes - the Prescriber
•
therapeutic training, drug knowledge and experience
•
knowledge of the patient
•
perception of risk
•
physical and emotional health
Causes - Patient & Team
•
patient characteristics
•
complexity of individual case
•
poor communication
•
nurses’ quasi-autonomous role
Causes - Environment & Task
•
high workload
•
time pressures
•
distractions and interruptions
•
failure to undertake review
•
monitoring reminder systems
Causes - Computing &
Interface
•
selecting wrong drug or dosage on pick lists
•
overriding interaction alerts
•
unnecessary/inappropriate alerts
•
failure to maintain accurate electronic records
•
poor quality correspondence
Defences
•
issuing new prescriptions
•
supporting patient decision making
•
dispensing prescriptions
•
monitoring patients
•
amending prescriptions from outside correspondence
•
processes supporting medicines management
Personal Prescriber
Strategies
•
read aloud printed prescriptions to help check patient understanding and allow
prescriber to check accuracy
•
clarifying specialist recommendations where these go beyond GP’s comfort zone
•
review newly prescribed medications within 6 weeks
•
add repeat medications only when patient stable
•
confirm important information with patient even when well known to prescriber
•
ensuring prescribers are competent to use all important features of e-prescribing and IT
support systems
Key Practice-Wide Strategies
•
adopt a formulary to increase familiarity with medicines prescribed
•
discourage verbal requests for repeat prescriptions
•
invest in non-medical staff training / dedicated team for repeat prescriptions
•
schedule blood tests 1 week before reviews / perform face to face medication reviews
•
do not delegate responsibility for difficult patients to locums or junior GPs
•
update prescribing record within 48 hours of receiving correspondence
•
appoint a practice prescribing lead, build a strong safety based culture, based on
blame-free communication
Key Health Technology
Strategies
•
code allergies in electronic records
•
robust alerts for high risk medicines
•
provide online access to medicines information, linking directly from clinical computer system
•
embed electronic formulary, use it to guide safer choices
•
separate drugs with similar names in pick lists
•
grade drug interaction alerts and give brief descriptions of interaction problems
•
run searches/audits to identify potential errors & patients requiring monitoring (particularly warfarin), use screen alerts
to highlight these
•
locum induction package to include familiarisation with information technologies available
Recommendations for GP
Training
•
greater prominence for therapeutics in curriculum
•
educational packages to support prescribing safety and
structured medication reviews
•
facility in ePortfolio to record educational activities
relating to prescribing
•
prescribing competence to be part of MRCGP
•
support for transition to independent practice
Recommendations for CPD
•
educational package to support reflection on and
support for identified learning needs from PRACtICe
study
•
strategies to support GPs dealing with high risk
prescribing scenarios
•
strategies to help GPs make best use of prescribing IT
•
strategies to improve prescribing safety systems
Recommendations for Clinical
Governance
•
conduct audits using prescribing safety indicators and
correct problems identified using evidence based
approaches
•
conduct significant event analyses
•
report prescribing adverse events (and near misses)
using National Reporting and Learning System