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3 GPs' views

Three GPs share their approach to a practice problem

Is missing

cancer drug

theft or admin

error?

case history

Yours is not a dispensing practice but does buy some drugs in for personal administration, mostly by nurses. You find the PCT drug payment statements impossible to reconcile with scripts sent to the PPA, so accept them on trust.

This morning your practice nurse comes in to say she was about to give a patient his first goserelin injection after receiving his diagnosis for cancer, but there were none left in the cupboard. When she last gave goserelin a couple of weeks ago, there were two in the cupboard; these seem to have disappeared without trace.

Your practice has six partners, two salaried doctors, a GP registrar and two full-time nurses, all of whom have access to the drug cupboard. The district nurses also come in to pick up flu jabs and so on. This year the practice was unable to account for 20 of the 3,000 flu jabs you bought.

Dr Mabel Adhagiuno

'This is a good opportunity to set up a reliable system for stocking and auditing drugs'

The missing goserelin has highlighted the underlying problem: there does not seem to be an effective system to audit the stocking and administration of drugs. Missing drugs is potentially serious and this is compounded by the fact that goserelin is very expensive. It is even more worrying if there is the potential for controlled drugs to disappear.

Many people have access to the drugs cupboard and this is a good opportunity to set up a more reliable system. It is important to discuss with the practice manager how she orders the drugs, what records she keeps and how she claims for payments from the PCT. It would then be helpful to look at any existing drugs book to see if all the data is correctly recorded. There may be patterns and discrepancies that shed some light.

In a busy surgery, we have all found ourselves having to run somewhere to pick up an injection to administer to a patient and blithely forgotten about recording it.

The district nurses are an unknown quantity and may be attached to different practices with varying policies about drug usage and administration. They are just as likely as anyone else to take drugs without recording them. So it would be good to discuss the problem openly with the primary care team.

Together you could try to come to a decision about the best way to administer drugs in the practice. People might also have helpful ideas about why there is such discrepancy between the PCT's drug payment and prescriptions sent to the PPA. If there is more efficient auditing of the drugs, the practice can challenge the PCT's drug payments.

Good organisation also cuts down the possibility of misappropriation or maladministration of drugs.

There may simply be one weak link in the chain, responsible for the missing drugs. Conveying to the whole of the primary care team how drugs are administered is vital ­ without neglecting staff who are not permanently in the practice such as locums, the GP registrars or district nurses. In this practice, informing other team members about any new medication requirements is important too ­ another patient unknown to all may also now need goserelin.

Ultimately, the 'mystery' of the missing drugs may not be such a mystery after all but simply lack of communication.

Mabel Adhagiuno is

a part-time sessional GP in Croydon and is also practises homoeopathic medicine both on the NHS and privately

Dr Trevor Rees

'It is unlikely somebody has stolen goserelin to sell on eBay'

It's unlikely that somebody has purloined the goserelin injections to sell on eBay, so the assumption must be made that these two injections have been given but a prescription hasn't been generated.

This could be a costly incident, but it should be possible to track down the patients who currently receive goserelin with a simple computer search, so all should not be lost. However, this practice has a bit of a mess on its hands with its previous missing flu jabs, so something has to change.

This scenario would make an ideal 'significant event' to evaluate, and it would be an opportunity to remind all members of staff involved in giving injections about the necessity of good record keeping and following protocols to generate a prescription for each item dispensed without attaching blame.

For the future, the most important point is to have a register of patients receiving goserelin, and each injection ordered should be allocated to a specific patient, marking the box with the patient's name.

All members of the nursing and medical staff should be reminded that the practice buys these drugs and only gets recompense by submitting a prescription to the PPA. New registrars might not be aware of this, and so information about dispensing drugs should be part of their initiation pack.

When a drug is dispensed, there should be a log signed by the person giving the injection with the date and the patient involved. This should be checked by the practice manager to reconcile drugs dispensed with prescriptions generated.

Finally, the worst culprits for taking flu jabs out of the fridge, giving them to patients and forgetting to make a record of it are the doctors, so it might be worth barring them from giving any drugs by injection except in an emergency.

Trevor Rees finished VTS

in 1983 ­ he is a partner in a

six-partner training practice and an undergraduate tutor at the University of Birmingham Medical School

Dr Alex Williams

'Video surveillance of the drugs cupboard could help us identify

the culprit'

This clearly raises the possibility that someone is misappropriating the drugs in a fraudulent way and it is not clear who is responsible. In the first instance, I would want to gather more information. Presumably non clinical staff may also be aware of where the keys to the drug cupboard are kept.

I find the concept of somebody stealing in the workplace difficult as it is not something I can easily understand. Maybe it is because we have and you have not justifies it in the perpetrator's mind ­ but not mine.

I might start with the practice manager and try to account for the missing vaccines and injectable hormones. Perhaps there has been a genuine reason or an administrative oversight that can explain everything. If not we may have to cast our net a bit wider.

I would hope I could trust all my partners (but stranger things have happened), so I may talk to a selected group in the first instance to plan our strategy.

Careful surveillance of the drugs cupboard may be necessary. We should check our controlled drugs for any discrepancies and this may give us enough to involve the police in our investigations. If the business is being defrauded this is an appropriate step anyway.

We should contact the clinical governance lead at the PCT to discuss our course of action and possibly also the LMC, which may be able to tell us if any of our personnel had been involved with anything like this before.

The situation has the potential to become unpleasant if not handled carefully. It may come to setting up secret video surveillance of the drugs cupboard to identify our culprit. If we do find evidence what do we do?

It would probably be grounds for immediate dismissal and we would have to check the contracts of employment. Whether we involve the police or report to the GMC or an appropriate professional body may be a decision for the partnership.

Alex Williams is a GP and trainer in Exeter

Learning checklist

Personally administered drugs

· Drugs administered by a GP can be bought in from the manufacturer or

via the pharmacy, then their costs can be claimed back via a form which is sent off monthly to the Prescription Pricing Authority.

· The benefits are convenience for the patient, no prescription charge for the patient, profit for the surgery from buying at a discount and claiming its full cost plus container allowance, dispensing fee, etc.

· The disadvantages are that the practice will end up paying for any injections which are bought but not accounted for, and also for drugs that go out of date. There are also administrative costs for the practice.

Investigation of missing drugs

Significant event analysis provides a good framework for investigating this problem

· First, the facts should be found out ­ over what period have drugs been mislaid, who gives injections, orders and sends in PPA forms and what appears to have gone missing.

· Then assemble everyone in a blame-free atmosphere and try to work out what happened and why.

· Arrive at possible ways to prevent the error in future. This involves tracking the process from buying the drugs to giving the injections, recording those consultations, collecting details of all patients involved and sending off the claim. It is important to ensure all staff are aware of how the system works and that temporary staff such as locums are not allowed to bypass the system.

Monitoring

· Stock control might involve using a book to record this or setting specific Read codes. For example 'goserelin given' can be Read coded and prescriptions checked against a monthly search on this code. This can be checked against a goserelin register. Placing responsibility on one administrative person to look after this is usually helpful.

· Get drugs with the latest possible expiry date to reduce wastage.

· What if someone is stealing the goserelin? Fraud prevention policies in practice usually concentrate on financial transactions and this sort of theft might be difficult to detect. If use of the drug over a three-month period greatly exceeds the number of patients who are on this treatment for prostate cancer that should raise suspicions that all is not well.

· Make sure the practice is keeping up-to-date controlled drug books and storing them in locked containers. It would then be worth looking at usage of vaccines and other drugs the practice buys in.

· The PCT pharmaceutical adviser may be able to help with your inquiries.

Richard Stokell is a GP in Birkenhead, Merseyside

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