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Pharmacist picks up GP's dangerous mistake

Case history

Mrs Smith comes in to see you as an extra. She says that Dr A, one of the partners, prescribed something for her yesterday, but the pharmacist has told her it will react dangerously with one of her other medicines, and that Dr A shouldn't have prescribed it at all.

How do I establish the facts?

What patients hear is not always what has been said or intended; many reported comments from other health professionals can sound outrageous, but when you unpick them, it is often easy to see how misunderstandings arise.

If Mrs Smith is angry or frightened, her choice of words may be rather dramatic. Empathising with her concerns, then asking exactly what was said may reveal that the pharmacist had simply raised a query and suggested rechecking the prescription before dispensing it. But you will need to ascertain whether there is in fact an interaction between the drug and her current medication. Quite often there is a theoretical or actual interaction which must be balanced against the potential benefit to the patient.

The pharmacist, who does not have all the relevant information, will not know why Dr A has decided to disregard the interaction, and Mrs Smith can be reassured that the prescription is correct. But if the interaction is potentially serious, you must take action.

Where can doctors get information on safe prescribing?

Have a copy of the BNF to hand at all times. A practice formulary can help; familiarising yourself with a limited number of drugs means you are less likely to fall foul of unexpected interactions and contraindications. Many GP computer systems have warnings that alert the prescriber to interactions, but although these are useful they can sometimes be alarmist, and do not absolve the prescriber from responsibility.

Computerised decision support such as Prodigy can be helpful, and can be accessed via the National Electronic Library for Health, together with other online resources, such as Bandolier.

Most practices have regular prescribing discussions; your local PCT and PBC group will also have prescribing advisers and/or a drug information service.

What are the duties of a pharmacist?

The Royal Pharmaceutical Society of Great Britain Code of Ethics and Standards says: 'Every prescription must be professionally assessed by a pharmacist to determine its suitability for the patient.'

This improves patient safety, and many GPs have reason to be grateful to pharmacists who have spotted their prescribing mistakes. These range from inappropriate quantities, such as 28 steroid inhalers on one script, to major interactions such as erythromycin and statins.

Pharmacists can make certain amendments to GPs' prescriptions, adding the annotation 'prescriber contacted', but the script must often be returned for the GP to rewrite. As pharmacists become independent prescribers, it will be interesting to see what safeguards will be developed. Like us, pharmacists have a duty of care to their patients, and must treat colleagues in a professional manner.

What should you say to Mrs Smith?

Your choice of words could have major repercussions for Dr A or the pharmacist. We must not unjustly criticise or undermine colleagues, yet we have a duty to tell the truth. The best course of action may be to call a halt, and tell her that you will contact her after speaking to the doctor and/or pharmacist in question.

But if the situation is urgent, or the individual is not available, you may need to make a judgment on the spot about what to say and what to prescribe, remembering that the patient's interests are paramount.

How do we give negative feedback to or about colleagues?

Negative feedback is difficult to give and to receive but we all have to do it at times. As a general rule, it should be done in private, with sufficient time available, but this is not always possible. In difficult situations it may be worth having a third party present and/or keeping records. It would be wise to discuss the matter with your trainer first.

Telling someone straight out that they have made a mistake carries risk – you may be wrong, there may be extenuating circumstances, or facts that you are unaware of, and the person may react very negatively.

Asking to discuss a problem that has come up, followed by a simple statement of the facts as presented to you and a request for clarification, will, with luck, trigger a calm discussion and an appropriate outcome. This should include reinstatement of the original prescription or agreement on an alternative. Mrs Smith will need to be informed, and either reassured or directed to the practice complaints procedure if she is dissatisfied.

If it appears that it was in fact the pharmacist who had acted/spoken inappropriately, then you and/or Dr A will need to have a similar discussion with him, pointing out that he has undermined Mrs Smith's trust in the practice. If this is a significant or recurring problem, the practice may want to take advice from its defence society as to what action should be taken.

Most doctors are upset to discover that they have made a mistake and anxious to rectify it in person. Unfortunately this sometimes extends to morbid brooding and mental health problems for the doctor concerned, so it's important that negative feedback is seen as supportive rather than critical. Occasionally mistakes are a sign of underlying problems such as depression.

The incident may have wider implications and be worth treating as a significant event, leading to changes in the practice (and written up for QOF points and appraisal folders). Certain adverse incidents may need to be reported to the National Patient Safety Agency.

Melanie Wynne-Jones is a GP in Marple, Cheshire

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