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At the heart of general practice since 1960

Prescription error

Never think of

prescription errors as

trivial ­ writes

Dr Tanvir Jamil

rescription errors are often looked upon as a relatively minor problem. After all, the 'error' is usually the wrong name on a prescription while the drug and dose are correct. Somehow you pressed the wrong button (easily done with computers) or forgot to change the details so the previous patient or someone you were giving phone advice to is still on screen (easily done if you are tired, bored, rushed or distracted).

So while you are merrily putting Mrs Jones's history on Mrs Smith's notes, the patient herself (Mrs Jones) is off to the chemist, prescription in hand. If the patient is diligent, and there are precious few of these, she would have read the prescription and politely pointed out the error. You, a little red faced, would have apologised, provided the correct prescription and that would have been that.

But most patients trust their GP to get it right and will end up at the chemist waiting for the script. The pharmacist will call out Mrs Smith's name (for that is the name on the script) but Mrs Jones will continue to wait until her name is called. Of course this is not going to happen.

Eventually the pharmacist and Mrs Jones will realise something is wrong and the error finally reveals itself. You will then get a call from the pharmacist. This is not as bad as it sounds. In my experience pharmacists are very professional and ring to check you really meant Mrs Jones instead of Smith.

This is the time to thank the pharmacist profusely for picking up your mistake. They will probably ask you to send the correct prescription and that will usually bring the matter to a close. You will need to correct the details on the computer and contact the patient to apologise. No matter what the error, an apology often goes a long way in restoring patient confidence and the doctor-patient relationship.

If you cannot contact the patient by phone, write instead. To you it might seem trivial, but to the patient it could mean a great deal and could reflect on the way she sees you as a professional.

Things that can go wrong

 · Different names are relatively easy for the pharmacist to spot but what if names and ages are similar?

 · Suppose the patient takes the wrong drug (penicillamine instead of penicillin).

 · Confidentiality may have been breached by giving out wrong prescription details.

 · Errors can still occur even if the name and address are correct. The dose and frequency may be wrong, especially if the specialist has made a recent change.

 · The patient may have an allergy not as yet transcribed on to the computer.

What to do if a patient complains

Follow your practice's complaints procedure. The overall gist of your reply should be to apologise, explain what went wrong and how the practice will learn from this mistake. You should indicate what procedures the practice intends to put into place that will minimise the chances of this happening again. Most patients genuinely complain to make sure the same mistake does not happen to someone else.

How can I prevent mistakes?

Repeat prescribing is potentially a huge source of error and the fact that relatively few occur is a testament to new computer systems and good staff training. You can minimise errors by doing the following:

 · Use repeat prescription slips only ­ verbal requests can lead to mistakes.

 · Try to ensure the patient's usual doctor signs repeats.

 · Patients requesting non-repeat items should talk to their doctor first.

 · Review drugs annually (are they still required, do they need to be monitored and is dosage still appropriate?).

 · Put systems in place that update medication details when specialists' letters indicate a change in drugs, frequency or dose.

Prescription errors are more likely if we are rushed or busy. Try to relax. If there are 30 extra patients waiting to see you, slow down a bit ­ most can wait an extra few minutes. Get in the habit of looking at the computer before calling in the patient.

When writing or printing out a prescription remember the following.

 · Check the patient's name, address and DOB ­ with the patient, not the computer.

 · Ask about allergies (even if not listed).

 · Warn about COC interaction with antibiotics.

 · Take a look at the printed prescription before signing ­ is it correct?

 · If you discover the error after the patient has left, try ringing up the patient's mobile, home and/or local chemist. If all else fails you might need to visit.

registrar

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