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Repeat prescribing: Don't repeat the risk

Cork-based GP Dr Diarmuid Quinlan and pharmacist/GP intern Dr Paul Ryan provide some top tips on avoiding errors when repeat prescribing

Is this a familiar scenario in your practice?

Busy receptionist answers phone: Mary Murphy wants her “usual tablets”. Receptionist writes a long list of medication on a sticky note while trying to avoid eye contact with another patient standing before her, though it’s difficult to hear over the radio blaring in the crowded waiting room. GP hovers impatiently at her shoulder with an urgent request.

Later, the receptionist finds time to generate the repeat prescription, trying to remember exactly which of the four Mary Murphy’s on the practice list actually phoned. Adds script to the large pile awaiting GP’s signature. GP is running late, and quickly signs a bundle of repeat prescriptions between consultations (without the “usual rigorous” checking!). One in 550 repeat prescriptions contains a serious error.1

Could this be you? Repeat prescribing can be a win-win situation: good for patients and good for doctors. It is convenient for patients and practices can experience a more structured workload, fewer “urgent” requests, fewer phone calls and less traffic at reception.

Repeat prescribing has been described as: “A partnership between patients and prescriber that allows the prescriber to authorise a prescription so it can be repeatedly issued at agreed intervals, without the patient having to consult the prescriber at each issue.”

However, “The authorising prescriber must ensure that arrangements are in place for any necessary monitoring of usage and effects, and for the regular assessment of the continuing need for the repeat prescription.”2 Repeat prescribing accounts for some 75% of prescriptions issued in general practice, with approximately half of all patients receiving repeat prescriptions.3 One in eight patients has prescribing or monitoring errors in their repeat prescription.1

There are none so blind as those who will not see

Repeat prescribing is a deceptively complex process, involving over 20 steps – from the initial decision to prescribe, to the patient finally swallowing the medication.2 Errors can, do and will arise at any of these steps.

Patients, practice staff, GPs and pharmacists all have a role to play to minimise error. Hospital prescriptions add a further layer of complexity and enormous potential for serious error. Safe repeat prescribing is everyone’s responsibility. Ultimately, the doctor that signs the prescription is legally responsible. If you think you don’t make mistakes in your repeat prescriptions, you’re probably wrong. These unseen errors, or “unknown unknowns”, pose a great risk to patients and physicians. Ask your pharmacist for prescribing errors you make this month – it will make for sober reading!
Patients, practice staff, GPs and pharmacists all have a role to play to minimise error

Why this medicine?

The clinical indication for a repeat medication should be explicitly documented in the patient record. Kill two birds with one stone: audit your repeat prescriptions for safer prescribing and fulfil your CPD audit requirement at the same time. You could audit warfarin; audit four parameters, eg, date commenced, clinical indication, target INR and duration of therapy; or audit methotrexate monitoring.

How – and when – do patients request repeat prescriptions?

Written requests are far preferable to verbal requests; the opportunity for error is reduced. Most practices still accept telephone requests. Many practices have a designated receptionist with protected time in a quiet location to prepare repeat prescriptions. This can prove efficient while reducing potential for error. Electronic requests are fast approaching...“Bí Ullamh”.

“Can’t I just wait for the doctor to sign it?” Sound familiar? Patients need to know how your repeat prescribing system works. Use every available opportunity to educate patients about why it takes three days to safely prepare and rigorously check the prescription. The receptionists, pharmacists, GPs, practice website and leaflets should all reinforce the process.

We all make dental and hairdresser appointments well in advance; surely patients can request medication in a timely fashion! I ask for three working days’ notice. It’s really important for others in your team not to undermine this timeframe by suggesting it will be ready “later today”.

Ensure appropriate clinical review 

In your practice, is clinical review usually an “ad hoc” opportunistic review, or a systematic review of the patient, their illness and management? A useful strategy is to issue sufficient medication until the next clinical review is due – this reduces the number of repeat prescription requests.

Patients requesting repeat prescriptions either early or late should raise concerns about possible overuse or underuse of medication. Synchronising the clinical review and quantity of medication issued is highly convenient for patients and the practice.

You must be confident the medication is appropriate, and that all necessary monitoring is undertaken

Signing the prescription

The doctor signing ideally both knows the patient and has direct access to the patient file. You must be confident the medication is appropriate, and that all necessary monitoring is undertaken. What happens when you’re on holiday? Is the locum placing both patient and practice at risk?

The primary-secondary care interface

What happens when medication changes are recommended upon discharge or from hospital OPD? How do you manage prescribing based on recommendations of a hospital consultant? For patients discharged from public hospitals, pharmacists “are authorised to dispense up to a maximum of seven days’ supply” in certain circumstances.5 Who amends the patient file?

Only the GP should add, delete or amend medications. Doctors should never ask, expect, or allow the secretary to do this. When should changes be made? Medication changes should be made upon receipt of the hospital letter. The UK GMC recommends that “any changes to the patient’s medicines are critically reviewed and quickly incorporated into their record”.6

How do you notify drug changes to the pharmacist? Do you just delete the unwanted medication, or amend the dose? This may result in a phone call from a concerned pharmacist. What about explicitly writing “Atenolol discontinued” or “Ramipril dose increased” on the script? This may avoid unnecessary phone calls from an astute pharmacist, while enhancing clinical governance.

Uncollected prescriptions

What happens in your practice? Do they languish at reception, or are uncollected scripts systematically returned to the prescribing GP for review?

The pharmacist

Is your pharmacist a source of inconvenient phone calls or an esteemed colleague? You may be just one step away from a serious prescribing error. Pharmacists are ideally qualified to monitor compliance, encourage appropriate monitoring and identify drug interactions.

Our repeat prescribing protocol states: “We greatly value the support and vigilance of our pharmacy colleagues. A pharmacist phoning with a medicine query should always be put through to the appropriate doctor.”

A win-win situation

Is repeat prescribing in your practice a high-quality, seamless, safe service for patients, harnessing the unique skills and knowledge of all staff in the process? Or is it a high-risk, errorprone, “ad hoc” activity? Your practice, your patients, your reputation, your decision. Make your repeat prescribing a win-win situation.

Your practice, your patients, your reputation, your decision. Make your repeat prescribing a win-win situation

High-risk patients and high-risk medications

Medication errors make up a fifth of all errors occurring in general practice, and many of these are preventable. Some patients are especially likely to experience serious adverse events due to repeat prescribing errors.2 These include:

  • Patients over 65 years and under 16 years of age
  • Patients on four or more medicines
  • Patients recently discharged from hospital and/or attending hospital outpatient departments.

The primary-secondary care interface is especially hazardous. All medicines are equal, but some are more hazardous than others. Some medicines frequently cause serious harm, warranting special care and rigorous monitoring, including:

  • NSAIDs
  • Benzodiazepines
  • Oral and topical steroids
  • Oral contraception
  • Anti-depressants
  • Opiates
  • Potentially toxic medicines: methotrexate, DMARDs, lithium, azathioprine, warfarin, “biologics.”

You should assess your current repeat prescribing protocols and audit methotrexate and lithium monitoring to expose previously unrecognised risks.

References

  1. Silk N, What Went Wrong in 1,000 Negligence Claims, Health Care Risk Report(2000)
  2. NHS National Prescribing Centre (UK), Saving time, helping patients: A good practice guide to quality repeat prescribing (2004)
  3. GMC (UK),Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study 
  4. MPS factsheet, Safe Prescribing (2012)
  5. S.I. No. 540/2003 — Medicinal Products (Prescription and Control of Supply) Regulations 2003 
  6. GMC (UK), Good Practice in Prescribing and Managing Medicines and Devices(2013)
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