Medication errors are one of the most common reasons for legal claims. Dr Karen Roberts explains how to prevent them
It is perhaps not surprising that medication errors occur. More than 880 million items were dispensed in the community on prescription in England alone during 2009 .
Medication errors are one of the main reasons for claims settled by medical defence bodies on behalf of GP members. GPs bear professional responsibility for the systems they run within their practice and may even be held responsible if errors are made by a non-medical member of staff.
The damages and costs can vary. I’m aware of one case where claimants were paid £1m for multiple-drug prescribing resulting in cardiac arrest and brain damage, while others settle for as little as £500.
Fortunately, it’s rare for medication errors to result in harm to patients, but it’s important for practices to have systems to prevent them. Here are some key tips.
Review procedures for long-term medications
Many claims for medication errors relate to the failure to monitor side-effects, particularly for drugs such as hypnotics and steroids.
To combat this, practices should have a system of reminders for GPs to review patients on long-term medication to check compliance, dose requirements and side-effects.
Practices should also ensure patients are recalled for examination and tests at the correct intervals, to monitor their condition, the medication and to ensure the drug is still necessary.
Develop a protocol for repeat prescribing
Many patients on long-term medication will be issued with repeat prescriptions, but it is important to have robust systems to review and monitor repeat medication.
Develop a protocol – including how many prescriptions can be issued before review and who is responsible for updating medication – and make sure all staff are trained in it.
Patients also need to be informed about the policy, for instance through practice leaflets and notices in the waiting room.
If your computer system allows only a set number of prescriptions to be issued before review, make sure this cannot be overridden.
Develop drug templates
Breakdowns in communication often result in medication errors. This may happen when patients are not informed about the risks of a treatment or there is a failure to get consent from the patient or the parent or guardian before administration.
Consider developing written templates for commonly prescribed drugs. Ensure patients are given enough information about their medication, including how and when to take it, possible side-effects and interactions, the length of the course and when to return for review.
Have protocols for the administration of child and travel vaccines – there have been cases of practices receiving a claim for administering an unnecessary vaccine. When children are vaccinated, ensure authority from parents is recorded.
Record allergies consistently
Other problems with prescribing arise when patients receive a drug to which they have a known allergy. Steps you can take to prevent this include checking the patient’s past clinical history and concurrent medication, along with any known allergies or hypersensitivities – particularly when prescribing antibiotics.
It is also important to ensure that allergies are recorded consistently – particularly when your practice has a dual system of paper and computerised records.
Review drug storage
In an emergency, mistakes can occur if drugs are not stored safely. In one claim, a GP administered 30mg of diamorphine instead of 10mg to a patient who collapsed in the surgery after complaining of chest pain. The higher dose was given because the drugs were stored next to each other. Realising the mistake, the GP was about to give naloxone to reverse the effects, but realised it was out of date. The patient suffered a respiratory arrest.
To prevent this scenario, ensure there is a system to rotate drug supplies and dispose of expired items. Also consider storing certain drugs separately:
• those that have similar names (such as Depo-Provera and Depo-Medrone)
• those of different doses (for instance 30mg and 10mg ampoules of diamorphine)
• those with similar packaging (such as some vaccines).
Make routine checks before drugs are administered
Claims often arise from an inappropriate drug being prescribed, for example because it was contraindicated by a concurrent condition such as pregnancy.
It is important to have a system to ensure all drugs are checked before they are administered – particularly when prescribing off label or when calculating reduced doses for children.
Mix-ups can also arise when patients have the same name, so that patients are prescribed the wrong drug. This can happen when records are not available, or when the wrong computer record is viewed by mistake. GPs should check the identity of patients during each consultation, to ensure they are viewing the correct records, and before administering a drug.
Take extra caution with shared care
When the practice has been asked to continue prescribing a treatment started in secondary care, GPs should be confident they have enough information to prescribe drugs safely.
There have been problems with drugs prescribed under a shared-care arrangement (for instance, methotrexate). The responsibilities of other professionals for following up and monitoring the patient should be clarified.
Develop an adverse-incident reporting system
When a mistake happens, it is important to learn from it.
A practice should explain to the patient that a mistake has been made and apologise, even if the patient isn’t harmed. It should also have clear systems to report adverse incidents so that the whole practice can learn from mistakes or near misses.
Dr Karen Roberts is a medicolegal adviser at the Medical Defence Union
medication-error claims settled over two years
• Problems with the long-term administration of medication (21)
• Wrong or inappropriate drugs (17)
• Dose error (14)
• Failure to prescribe (4)
• Administration error (3)
• Prescribing to a patient with a known allergy (2)
• Other (8)
Source: MDU audit of 69 claims settled over two years