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GPs buried under trusts' workload dump

DH to launch crackdown on prescribing errors

GP prescribing could come under scrutiny as part of a Government drive to cut medication errors.

The Department of Health said the scheme was likely to be launched early next year, at the latest, and that it was currently enlisting experts to set out its remit.

Primary care minister Steve Brine MP told delegates at the Royal Pharmaceutical Society Conference yesterday that health secretary Jeremy Hunt was working closely with NHS England chief pharmaceutical officer Keith Ridge on tackling prescribing errors.

This work is likely to focus on:

  • Improving communication and preventing errors when patients move between care settings;
  • How pharmacists can support GPs and care homes; 
  • The impact and uses of e-prescribing; and
  • Errors in seven-day services.

It also said there would be a public-facing programme focused on patients’ understanding of medicines, and a piece of work looking at any problems that may arise in the pathway from prescribing to dispensing and monitoring.

Mr Brine said: 'Studies currently indicate that up to 8% of prescriptions have a mistake in dosage level, course length or medication type –a risk which the WHO identifies as “a leading cause of injury and avoidable harm in health care systems across the world".

'Patient education and safe management of information will be at the heart of our efforts to tackle this serious issue. For example, we will need to improve how we use electronic prescribing, as well as how we transfer information about medicines between care settings, where there is significant scope for errors.

'Fundamental to this process is clinical leadership – and that begins with fostering the debate, inside and outside government – around how we can make these essential improvements to our healthcare system.'

A 2012 GMC analysis of prescription items found roughly one in eight patients was affected by a prescribing or monitoring error and, although only one in 550 errors was found to be severe, prompted changes to GP training.

A more recent audit of 500 practices’ prescribing, published in the BMJ in 2015, found around one in 20 patients received a prescription that should have been avoided as it could worsen their condition or interact with another medication.

GP leaders said at the time that pharmacist-led medication reviews could help boost safety and take pressure off GPs.

Readers' comments (26)

  • Azeem Majeed

    In a study of clinicians' views on priorities for improvement of medication safety in primary care, the top three problems were incomplete reconciliation of medication during patient ‘hand-overs’, inadequate patient education about their medication use and poor discharge summaries. The highest ranked solutions included development of a standardized discharge summary template, reduction of unnecessary prescribing, and minimisation of polypharmacy.

    https://goo.gl/6EgS8x

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  • In my study of one person's views on priorities for improvement of the NHS and primary care, the top problem was Jeremy Hunt.

    That is all.

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  • The answer is of course that drug prescribing remains with the provider who is managing the condition.....not transfer to GP....hand offs are always risky

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  • The approach needs to be less about 'punishing' doctors for getting things wrong and more open reporting of errors - Book 'Black Box Thinking' by Malcom Gladwell should be a start point in this thought process.

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  • "Reduction of unnecessary prescribing" .... which is why all GPs should have the option of social prescribing. Not just an issue of ensuring engagement with patients in what matters to them, but clearly a patient safety issue.

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  • All valid points! Standardized Discharge Letters , Minimal Prescribing and Appropriate Handover to GP are Essential Tools to minimize prescribing errors! Jeremy Hunt is not supporting Primary Care adequately!

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  • Jeremy Hunt is not perfect but has been and is a champion for patient safety, something we should all be champions for. Question to OBI - if Jeremy Hunt is top of the list of the cause of the problem, what is your ranking on that list?

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  • Cobblers

    Anyone going to query monthly prescribing which supposedly saves waste but also decreases compliance?

    If circumstances permit doing an annual script instead of monthly would reduce the workload by 12X. Of course 3 monthly or 6 monthly scripts would be more likely.

    Less workload, less errors, but pharmacists might suffer!

    What's not to like.

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  • In aviation, systems are designed to reduce errors. The pilots aren't constantly blamed and told to try harder. Look at Martin Bromiley's human factors work featured in Matthew Syed's Black Box Thinking, and the culture/hierarchy barriers in Malcolm Gladwell's Outliers. It is a system designed to produce errors. Not duff clinicians who need a good beating or yet more training.

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  • The whole prescribing process is deeply flawed at system level - at worst it is an unmanaged production line of FP10 with only minimal
    oversight by a clinical system that is on its knees from transaction overload.
    I doubt that the findings by Arnold Zermansky in 1995 in Leeds published in JRCGP are much different today - only 50% had a clinical review in the previous 18 months in his study group of training practices. In a personal communication he thought in ordinary practice it was nearer 33%.
    The arrival of pharmacist as a key role inside GP surgeries is crucial as a manpower issue, but do is root and branch reform inside practice prescribing systems as a developmental strategy. More bodies added to a flawed system will not help in the long term.

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  • Just one issue for me: who is going to set this new "standard"?

    If it lacks grassroots input, and turns into "you can't have this 5d course of steroids because it will worsen your diabetes" then may our gods help us all!

    If it means all prescribers using one computerised record, with a permanent audit trail, then about bl**dy time. I don't enjoy transcribing hospital "suggestions" when the outpatient prescriber is reading from a mess list typed at the point of referral some 3 months earlier. Yes I know consultants work hard and the majority are excellent: do you realise that we sometimes have only a few seconds per decision when it comes to some prescribing, often in early evenings.( I have now changed my routine to avoid this.)

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  • Sorry, should read "meds list".

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  • A prescription with 2 interacting drugs is only a 'drug error' if enhanced life expectancy is an undesireable outcome. Look at hypertensive prescriptions: any 2 antihypertensives always interact (to lower the blood pressure) !
    To Cobblers: monthly prescribing would be wonderful - it would reduce workload about 28x Why do we still have to sign a script on paper for every single day of the year for some patients, and every week for others?

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  • Response to Conbblers:
    Repeat Dispensing has been available since 2003 and is available electronically now as well.
    The uptake has been very very poor.
    From where I sit this is one of the great lost opportunities of the last 20 years.
    Interestingly where CCG have strategy of investing in pharmacists in primary care, eRD progress across their CCG is looking very good indeed.
    Worth adding to the planning discussions at local level.

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  • To me, 'removing medication errors' starts with having a decent system, with minimal copying (=minimal transcription errors).

    We need a national medication database for each patient, from which everyone works, whether in hospital, primary care, private medicine, community, OPD, wards... so there is an immediate understanding of what the patient is taking. (A single database doesn't mean a single software program to run it, BTW).

    Then we need a total absence of silly rules ('you can't put CDs on repeat dispensing' -- which I suspect was why Repeat dispensing never took off that well at the beginning).

    Then we need prescriptions which are written to cover clinical needs, not financial ones. All that faffing around to repeat prescriptions every month for longterm medication such as levothyroxine is simple wasting time and increasing the possibility of transcription and transmission errors (electronic and physical).

    Finally, we need time to make the decisions: and it's got to be unhurried and not pressurised. Tired, overwhelmed staff will make mistakes: it's not their fault as much as the system which creates that tiredness and that sense of being overwhelmed.

    ... and ONLY at that point should anyone start to investigate the competencies of the prescribers themselves (though will all the above in place, I suspect that the level of mistakes would already have dropped precipitously.)

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  • @Herbert: Misinterpretation- JH 'seems to be' a champion of patient interests. in reality, all he has done to destroy Primary Care and desecrate the profession only shows his true colours. He's a fiend not a friend and his sweet talk and conjured figures are a manipulation to which it is easy to succumb to. He does remain Public enemy number 1 as far as NHS is concerned unless there is a conviction that privatization through the backdoor is in the interest of patients.

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  • Herbert
    Do you truly, honestly think that Jeremy Hunt is a champion of patient safety?
    can we be provided with some supporting Evidence other than the guff he spews out of his own mouth?

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  • 2012 data. Since then we've had introduced: electronic prescribing (with integral alerts), Scriptswitch, Practice Pharmacist, and CCG Prescribing Management Team oversight.

    Firstly, I doubt the 2012 figure is correct.

    Secondly, with Jeremy Hunt failing to act on Francis's main findings and stifling NICE's work on safe clinical staffing ratios; ignoring staffing, funding and beds crises of his making; and hiding the damage that 2012 and subsequent reforms are doing to patients - I hardly think, 'Herbert', that he can be framed as a champion for patient safety.

    BTW, I am forced by prescribing software to choose "medication error" option when cancelling an issue of any drug on patients' medication list...which may cast some doubt on the quality of information that is being thrown at us.

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  • the best way to reduce error is to give us time to think about what we are doing. If I have an unhurried surgery usually I don"t need to prescribe anything anyway.

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  • AlanAlmond

    Medication reviews are part of QOF and I see multiple patients every day who come in soley for this reason. To be honest I don't find the increasingly frequent pharmacist medication reviews at all helpful, they rarely throw up much of clinical significance and mainly just duplicate work the GP is already doing and worry patients about side effects they weren't aware they had. The biggest source of medication error in General Practice arrises in the interface between hospital and primary care. I am forever being asked to prescribe stuff supposedly initiated in hospital with no correspondence to back it up...or having non prescribers in hospital telling patients to get me to prescribe something on their advice...or having specialist nurses from rheumatology or the IBD clinic expecting me to prescribe amber drugs with very little hand over and no shared care agreement. This problem is getting more and more frequent with the theme in all being ..that the GP (as the plonker who signs the prescription) carries the can, and the hospital (who ironically have crown indemnity) conveniently not responsible.

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  • Wasn't this the study that recorded a prescribing error if the dosing instructions weren't specific enough, ie contraceptive pill 'as directed' rather than 'take one by mouth every day for three weeks, then omit for seven days before starting again...' or lancets for BM tests 'as directed' rather than 'prick finger with sharp end, use a new needles for every test, dispose of safely...'
    Almost every script for prn medication or moisturiser fails this test. Flawed data

    Agree with Dr De'ath above. Most dodgy prescriptions I issue are for drugs recommended by single issue specialists at hospital, some of whom have no concern for anticholinergic load, glaucoma risk, renal function, or common sense, as long as they have recommended the latest untried flavour of the month therapy. Cardiologists seem to be the most reckless with huge statin doses, amiodarone, anticoagulants in the extremely frail to mention a few. Sad to say, single issue specialist nurses can also some of the worse offenders (heart failure, continence, IBD, parkinsons in particular), and its a difficult conversation with the patient to explain that the wonder drug they have been promised is not safe for them to take.

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  • I assume that all other prescribers (prescribing nurse practitioners, pharmacists etc) never make any prescribing errors! Not!! If GP workloads were not so overwhelming then likely fewer errors would be made or, as mentioned, then one wouldn't be pressured to prescribe a pill for every ill.

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  • I agree with Dr Azeem Majeed, but can only add that the time and workload pressure general practice is under will make matters worse, and Jeremy Hunt will blame us. I see a lot of dodgy prescribing coming out of secondary care. Still keen to minimize errors on my behalf.

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  • Why don't we refuse to prescribe secondary care initiated drug make them responsible for their prescribing and drug budget.Really annoying that our consultant colleagues don't get roasted for their prescribing like we do.When we take over their prescribing we sign the paper it becomes our fault and responsibility.

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  • its high time that this issue is addressed
    i have been advocating the integration of Pharmacists for a long time
    Medicines optimisation should be the top priority which will save atleast £150 million if not £300 million

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  • I've never really understood the transfer of prescribing from secondary to primary care. Anyone looking on would see it as an accident waiting to happen. If I am not certain of the exact regime I write for clarification. My biggest pet peeve is the "vitamin D low please prescribe according to local protocol".... not until you've discussed it with the patient yourself, and you can read the protocol and tell me the exact dose and duration

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