Venlafaxine Overdose
Issues identified
 Near miss-potential venlafaxine overdose
 Problem with communication with patient/family who were confused
regarding new medication regime
 Letter clear and consistent but followed above event by some days
Rash decisions
Learning points:
 The basics can sometimes be overlooked – an apparently trivial rash, as in this
case, can herald a more serious condition, which reflects the need for joined up
thinking.
 Clear and contemporaneous note-keeping is essential and this case highlights
the importance of adequate documentation. Clinical notes are legal documents
and any alterations or retrospective entries should be clearly marked and dated.
GMC guidance states that doctors should “keep clear, accurate and legible
records”. Alteration of medical records is a probity issue.
Repeat offender
Learning points
 GPs must take particular care when taking responsibility for prescribing
treatment commenced in the hospital sector. If you sign the prescription, you
are responsible for it, so make sure that it is correct. If a drug is unfamiliar,
don’t prescribe it if you don’t have the knowledge/experience.
 In shared care situations there is a reduction in risk if the initial prescription is
commenced by secondary care.
 Practices should have a system for ensuring all incoming mail is checked and
acted upon. There was a lost opportunity to correct the error when the
hospital letter was received.
 Repeat prescribing is particularly risky for locum GPs. Locums should
consider whether there is anyone better placed to do it, such as another GP
who is more familiar with the patients.
 Any GP doing repeat prescribing must ensure that the prescription is still
necessary/correct.
 This case highlights the importance of being open and honest if you make or
discover a mistake.