How to avoid major causes of prescribing error
A Government report has flagged up fatigue and excessive workload as important causes of GP prescribing error where it occurs Dr Jim Sherifi gives advice on how to avoid such mistakes
The avoidance of prescription errors is essentially based on good management practice. This includes in-built checks and balances where each member of the 'supply chain' physician, patient, pharmacist and pharmaceutical company is aware of, and comfortable with, their individual role.
As far as the physician is concerned, a GP undergoes rigorous training, which includes clinical pharmacology, before being allowed to practise. Such training continues throughout one's working life. Maximising the acquisition of knowledge can be achieved through the recording of adverse events or 'near misses' as they arise. These should then be discussed at scheduled clinical meetings.
In addition, the easy availability in the practice of reference manuals such as the BNF, Mims and the Drug and Therapeutic Bulletin is essential.
Though the doctor's knowledge is doubtless absolutely sound, he or she
needs to be ever-vigilant, no matter how hurried or tired.
Next we come to the pharmacist. Pharmacists are perfectly positioned to monitor any prescribing mistakes. These can then either be brought to the attention of the prescriber as they happen or collected and discussed at quarterly interdisciplinary meetings.
Pharmacists and pharmacy assistants undergo rigorous training, including continuing professional education. As from 2005, all pharmacy technicians will have to obtain NVQ qualifications and be registered before they can undertake functions such as 'checking' and dispensing. Use them!
Next, patients. In our dispensing practice patients are encouraged to report, in writing, any problems experienced in obtaining their prescriptions.
Errors occur when a system is under strain. So requests for repeat prescriptions should only be accepted in writing, preferably by the request form supplied on GP prescribing IT systems. The reason for this needs to be explained to the end user in order to obtain their understanding and compliance. Requests can also be taken by fax or e-mail.
Until universal patient-held electronic records are introduced, paper-based booklets on regimes requiring close monitoring such as methotrexate, lithium, insulin and so on can provide yet another layer for patient assurance.
Concordance and safety are enhanced by simple prescribing regimes incorporating once-daily dosage and combination drugs where practicable.
Finally, we should consider pharmaceutical companies. Drug companies provide an excellent educational resource for doctor and patient alike, but they do tend to squander some of that goodwill by the developing of 'me-too' drugs of marginal benefits which by unnecessarily increasing choice only contribute to confusion. The issue of names can also lead to confusion, such as the recent introduction to the UK market of Olmetec and Omacor, both cardiovascular products but of entirely separate drug class.
In summary, the administration of any drug always poses a potential hazard. Although the risk can be significantly
reduced through the inclusion of the suggestions made in this article, they are no substitute for continuing vigilance, which can only arise through better education, more time and less pressure.
Jim Sherifi is a GP in Sudbury, Suffolk
What to look out for
· Illegibility of script
Wherever possible scripts should be issued on computer. If not practicable then words should be written in upper case the length of time it takes to
do so is minimal.
Take care, especially in children where dose is based on body weight rather than age. An up-to-date paediatric formulary is invaluable.
· Computer software
Prescribing software still leaves a lot
to be desired. Confusion on names such as that between penicillamine and penicillin on a fussy and cluttered screen is still common but can be lessened by discussion with the software supplier. Likewise, 'alerts' can be made more personal and relevant and thus more genuinely alerting.
Chronic disease management protocols incorporating good clinical practice with regard to monitoring for example the recording of BP in hypertension or HbA1c in diabetes are gradually being incorporated into popular software systems.
· Practice formulary
In order to be manageable, simple and safe, the formulary must be limited to a minimum number of drugs in each class with buy-in agreed from all prescribers in the practice.
Hospital in- and outpatient letters in particular need to be seen as soon
as they arrive in the practice and any changes in medication put on screen immediately.