Pregnant patients received ‘inappropriate’ medication due to pharmacy coding errors

Exclusive GP practices have been asked to review records after pregnant patients at some pharmacies were ‘incorrectly coded’, receiving ‘inappropriate supplies’ of medications as a result.

NHS England undertook an investigation into the recording of pregnancy status in the Optum PharmOutcomes IT system for the Pharmacy Contraception and Pharmacy First Services, after receiving incident reports.

It found that ‘multiple records’ were found where a patient ‘has been incorrectly coded as pregnant’. It also found that some patients received ‘an inappropriate supply of medication’, including where patients have been coded correctly as pregnant and should have been excluded from the supply of medication.

In a message to practices in Essex, seen by Pulse, NHS England said that a clinical advisory group confirmed that this is a patient safety incident that ‘requires action to prevent potential harm’ to impacted patients, and that patients ‘must be informed in line with duty of candour guidance’.

Pharmacists and pharmacy technicians can now add updates from Pharmacy First, blood pressure and contraception consultations to GP patient records via the GP Connect Update Record functionality, which means that the coding errors transferred to the GP record although the functionality is not yet contractual.

NHS England told Pulse that GP practices were asked to review their records and take ‘any other action as appropriate’, but the commissioner did not confirm to Pulse how many patients have been affected by the coding errors.

A spokesperson for NHS England told Pulse: ‘We have been made aware of an issue which may have led to some patients being incorrectly recorded as being pregnant at some pharmacies – and have asked pharmacies and GP practices to review their records and take any other action as appropriate.’

Practices are not required to contact the patient unless following discussion with the pharmacy, they feel ‘it is appropriate to do so’, NHS England added, for example if the pharmacy has been unable to contact the patient after three attempts or if ‘follow-up action is needed by the patient’s GP’.

The records were ‘risk-assessed’ into priority order for action (see box) and pharmacies will contact patients to confirm their pregnancy status and will contact the practice ‘if any further action is needed’, including if the GP patient record needs to be amended or if the patient needs a follow-up.

Dr Neil Bhatia, a GP and records access lead at his practice in Hampshire, told Pulse that the coding errors could have ‘serious consequences’ for patients, as well as increasing workload for practices, and raised wider concern about Pharmacy First and the Pharmacy Contraception Service.

He said: ‘None of this fills anybody with confidence that this project is working – if the result of it is errors in GP medical records, it just becomes worrying.

‘If NHS England are trying to instil enthusiasm for these sorts of projects, they’ve got to make sure that there aren’t unintended consequences.

‘There are medications that are toxic to developing the foetus, or that may have severe or serious consequences, from severe injury to miscarriage.’

He added that the errors could mean a ‘huge amount of work’ for practices who will have to go through the records to remove the codes.

He said: ‘That undoes all of the benefits of system in a second, because all the time saved will now have to be spent, and then some probably, going through all the records.

‘The idea was to save GP time by not sending through pieces of paper that we then had to scan, and then somebody had to look at them, and then somebody had to add the appropriate code to the GP record, all of which takes a long time.

‘So the idea was that they would just do this directly, and it would come into our record to save us time. But the problem is that whatever they do ends up in our records and if they make a mistake, it ends up in our record.

‘We have to be aware that our GP record is now becoming even more critical, not just for our own practice, but for the people who work in our practice and the people who work outside of our practice, who are reliant on the accuracy of our record.’

It comes after the BMA warned that GPs could be liable for ‘abnormal or erroneous’ information entered by a third party into patient records.

The union raised GP liability concerns about third-party information being entered into the patient record once enabling the GP Connect Update Record function becomes mandatory in October.

Meanwhile, primary care minister Stephen Kinnock recently said that take-up of Pharmacy First is not where the Government ‘would like it to be’.