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Independents' Day

Inadequate nurse prescribing training will fuel adverse events

Giving nurse prescribers access to the entire BNF will have serious consequences for patients, warns Professor Hugh McGavock

Giving nurse prescribers access to the entire BNF will have serious consequences for patients, warns Professor Hugh McGavock

In 2003, the Department of Health began to roll out independent nurse prescribing, and by 2006 it had extended it to include the entire BNF. In doing so, it ignored specific advice from the Committee on Safety of Medicines that a full year's academic level training in both diagnosis and therapeutics should be given to all independent nurse prescribers.

Instead, it decided that 25 days' training – and half of it by distance learning – was sufficient to produce knowledgeable and safe prescribers. Nurses were then free to prescribe anything they would consider ‘within their areas of competence'.

This is bound to lead to an increased risk of preventable prescription-related illness, because the relative safety of modern drugs and the slow onset of any adverse effects can give prescribers a false sense of security when their underlying knowledge of pharmacology is inadequate.

Catalogue of concerns

Pulse recently obtained details of the number of items of medication prescribed by independent nurse prescribers from the NHS Business Services Authority. Analysing just one month's figures, from May this year, reveals a catalogue of concerns:

• There were more than 20,000 independent nurse prescriptions for the full range of antibiotics and antivirals.

• Amiodarone and cimetidine are being prescribed – both very risky drugs with dozens of potentially fatal interactions.

• A wide range of cardiac drugs is being used by nurses, including digoxin, ACE inhibitors, angiotensin receptor blockers and calcium channel blockers. Many of the digoxin prescriptions were for the higher dose tablet, and there were 98 prescriptions for the calcium channel blocker verapamil – a drug that should only be instigated by a cardiologist and prescribed by a GP.

• There were hundreds of prescriptions for diuretic-hypotensive combinations, including co-amilozide and co-amilofruse, both of which carry a serious risk of plasma electrolyte problems and are major causes of drug-related emergency admissions.

• Nurses were prescribing the full range of anti-diabetes drugs, despite diabetes being the most brittle and treacherous of syndromes, even in specialist hands.

• There were many prescriptions for antidepressants – after antibiotics, the most over-prescribed drugs.

• There were thousands of prescriptions for NSAIDs – the most dangerous drugs of all, accounting for more than 30% of all reported serious adverse drug reactions.

• Nurses had given out about 200 scripts for atypical antipsychotics, whose incorrect use may lead to permanent sequelae.

• There were a host of other drugs prescribed by nurses that are potentially seriously risky. These included more than 1,000 prescriptions for a-blockers, more than 100 of methotrexate and almost 500 prescriptions for erection enhancers.

Most of these drugs are suitable for a nurse to prescribe in a medication plan agreed with a doctor. Given nurses' entirely inadequate training in diagnosis and therapeutics (which of course is not the nurses' fault), hardly any of these drugs should be prescribed independently.

Currently, about 5% of emergency hospital admissions are the result of faulty GP prescribing (in the elderly the figure rises to 12%), despite the prolonged training that GPs get and the long period of supervision.

We may expect a marked escalation of preventable prescription-related disease from independent nurse prescribing on the basis of these figures.

Professor Hugh McGavock is visiting professor of prescribing science at the University of Ulster and a former member of the Committee on Safety of Medicines

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