Pharmacist interventions won’t solve script errors
A flawed analysis of prescribing errors has damaged the reputation of general practice, says Dr Mark Ironmonger.
On 2 May, the national headlines wallowed in how bad we GPs are at prescribing. According to the BBC, GPs were ‘making too many errors prescribing drugs'. The Daily Mail said our drug mistakes had hit 40% of the elderly, and the Daily Express put one in six patients at risk from our ‘blunders'. Little wonder GPs took a pasting, given the responses from our professional representatives about the need for ‘improvement' (from the GMC) and ‘more GP training' (from the RCGP). But are the ‘errors' really errors?
Many of the moderate errors recorded in the PRACTICE study were actually a result of poor medicine at a minority of practices leading to bad prescribing rather than systematic prescribing errors. This was particularly apparent in the list of scenarios subject to a root cause analysis.1
Of the 11 serious errors found, there were two obvious allergies that should have been flagged up by an effective use of IT. The other nine were down to inadequate INR monitoring, with eight of these from one practice involving three patients who clearly did not wish to comply with the district general hospital-run INR clinic. The study rightly stated that warfarin prescribing without access to INR test results was ‘the most important problem identified' – but failed to highlight that this was largely at one practice.
Some 69% of errors were down to ‘failure to request monitoring', which is not a black and white issue, and is subject to change. For example, simvastatin was cited as responsible for 10.5% of prescribing errors and 18.2% of monitoring errors. We don't know if these errors were due to a lack of biochemical monitoring – even though ‘fire and forget' is considered a legitimate strategy by NICE once efficacy and two sets of normal LFTs have been established – or whether the errors were due to a failure to specify ‘use at night', which some consider of limited significance anyway, and does not apply to some other statins. There is a legitimate argument to say it is more important that the patient takes the medication when they remember.
As a dispensing doctor, I have a natural interest in the prescribing and dispensing accuracy of dispensing practices. Of the report's 227 pages, unfortunately, only one discusses dispensing practice.
This concluded well-trained practice dispensers are a useful defensive strategy against prescribing errors. Dispensers are described as mitigating ‘the loss of the safety barrier [of a pharmacist]'. As well as screening prescriptions for errors, dispensers play a useful role in converting Latin prescription instructions into English for patients, and in identifying patients who need monitoring or medication review. A key contribution to patient safety is the dispenser's ability to make annotated changes on the practice computer system.
GP as well as pharmacy representatives leapt on the report's conclusions that pharmacist-led interventions, particularly medication review, have value in preventing prescribing errors.
Yet the report's own update of a systematic review of primary care interventions found pharmacist-led interventions were not effective at reducing hospital admissions and suspected adverse drug events. It added that because community pharmacists' interventions were not routinely documented on the patient's medical record, this could lead to errors being propagated to subsequent prescriptions.
Collaborative working with pharmacists brings benefits to patients. But before we embark on initiatives that may cost the NHS more than they save, we must be sure of the evidence base – and that must include a study of dispensing errors made by pharmacists. This report hands the press another stick with which to beat general practice. If the three patients from one practice who would not comply with INR monitoring are taken out of the equation, we are left with three serious errors, and none that caused harm to patients, out of 6,048 GP-issued prescriptions.
Our representative bodies should re-examine this paper and support the excellent service that GPs provide. But I fear on this occasion, the damage has already been done.
Reference: Avery T, Barber N, Ghaled M et al. Investigating the prevalence and causes of prescribing errors in general practice: The PRACTICE Study. GMC/University of Nottingham 2012
Dr Mark Ironmongeris a GP in Brenchley, west Kent, and a board member of the Dispensing Doctors' Association