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A solution to patient medication errors

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There has been a Government obsession to trim NHS costs at almost any cost. This is particularly apparent when managing drug budgets.

Don’t get me wrong – there are times when the NHS is fleeced by the pharmaceutical industry when prices are hiked.

For the last 20 years, the NHS has endeavored to fight this battle by encouraging us to prescribe generically. On the surface, this seems entirely reasonable – why prescribe Zyloric when Allopurinol is a tenth of the cost?

However, this tactic, which is often only a short-term measure, takes away the most important safeguard for our patients – the patient themselves.

If we only prescribed trade medications, then patients would always know exactly what they were taking – the drug name on the box, the box itself, the colour, the shape and the size of the tablet/capsule would never change.

However, once we started prescribing generically, the only constant is the name on the box, and often that is not obvious. The tablet/capsule itself may well be completely different from one script to the next, as the pharmacist endeavors to save the NHS cash.

I remember well that for the first three months of the generic prescribing policy, we were reassuring patients on a daily basis that even though the new tablets were a different size, shape and colour, in a different box and with a very different name on the front, they were actually exactly the same tablets.

The most important safeguard for our patients is the patient themselves

After three months, the phone calls stopped and our patients faithfully and unthinkingly take the medication that they pick up from the pharmacist.

So if a script for Chlorphenamine is inadvertently issued as Chlorpromazine (alas, mistakes still happen), then the patient will shrug their shoulders and simply swallow the new tablets.

I recently had to advise my father about removing one of his medications from his dosing pack – the GP had told him to stop a particular tablet. He takes a variety of medicines and I simply told him that he needed to remove the round white tablets – as described by the pharmacists on the dosing box. To which he quite reasonably replied ‘OK, but they’re all white and round!’

If the vast majority of tablets are all the same colour and shape, it’s easy to take the wrong medication.

It was at this point of exasperation that I happened upon the bleedingly obvious idea that medication should be standardised into colours and shapes, thus solving the problem of prescribing generically and the conundrum of almost all medications being white and round.

Helpfully, someone has already done the hard work – the BNF has chapters headed Gastrointestinal, Cardiac, Respiratory, Nervous System, Infection, Endocrine, Genito-Urinary, Immune System, Blood and Nutrition, Musculoskeletal, Eye, ENT and Skin. Thirteen chapters covered with 13 different colours.

Within these broad chapters, there are a number of different categories – usually about seven, which will niftily be covered with shapes. I appreciate that all beta-blockers will be in the ‘heart – antihypertensive’ category, along with calcium-channel blockers, but these could be further distinguished with a letter or two, such as ‘BB’ and ‘CC’.

The point is that patients’ descriptions of medication will suddenly be worthwhile – I think the red pyramid tablet is causing me problems, means much more than the round white one. Also, when we constantly change medication, as least the patient will know that they’ve still got to take the yellow triangles with a ‘P’ on one side.

I realise that every drug company on the planet is going to have to sign up to this masterplan, which, let’s be honest could have been drawn up by most five-year-olds – this isn’t rocket science. 

This small and rather obvious change in how we manufacture medicines has the potential to save the lives of vast numbers of people and make our lives as GPs considerably easier.

Dr Nigel Cowley is a GP partner in Bournemouth