Dr James Lucas, medicolegal adviser at Medical Protection, handles a call involving a prescription generated in secondary care
Mrs V, a practice manager, contacted the Medical Protection telephone advice line to seek guidance on the practice’s responsibilities when transcribing hospital prescriptions to General Medical Services (GMS) prescriptions.
Mrs V wished to clarify, in particular, the extent to which the GPs at the practice could rely upon the prescribing recommendations of colleagues in secondary care, when issuing such prescriptions.
Expert advice
Mrs V spoke to Dr P, an expert medicolegal adviser with a background in general practice, who also had a specialist interest in prescribing issues.
Dr P summarised the position with reference to the HSE’s handbook,1 noting that eligible patients who are provided with a prescription form on their discharge from hospital are required to request a GP, participating in the GMS scheme, to transcribe the prescribed items onto a GMS prescription form, in order for such items to be dispensed free of charge.
Dr P advised that there was a well-recognised risk of medication errors during the transition from secondary to primary care. He referred to an ICGP report on repeat prescribing, which noted that externally generated prescriptions, such as hospital prescriptions, require special attention given that they often get transferred into the repeat prescribing system without a face to face consultation.
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Dr P advised that the doctor signing the GMS prescription bore ultimate responsibility for it. This meant, for example, that in those cases where the dosages on the hospital prescription were illegible, the GP would need to consider contacting the issuing practitioner or service to confirm the correct prescription.
Dr P explained that the overarching medicolegal principle of prescribing was neatly summarised in the Medical Council’s guidelines: “[A]s far as possible, you should make sure that any treatment, medication or therapy prescribed for a patient is safe, evidence-based and in the patient’s best interests…”
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He went on to explain that transcribing a hospital prescription onto a GMS prescription was, essentially, prescribing at the recommendation of another healthcare professional. Dr P noted that the Medical Council had not made specific reference to the issue in its guidelines. However, prescribers could maximise patient safety by ensuring that the prescription was needed, appropriate for the patient and within the limits of their competence to prescribe.
Dr P followed up Mrs V’s enquiry, in writing, with some clinical vignettes to illustrate safe approaches to prescribing in these circumstances (see below).
Is the prescription needed?
A young female patient was admitted to hospital with appendicitis. Following discharge, a relative presented a hospital prescription form to the patient’s GP. The GP noted that a number of cardiac medications were included on the hospital prescription form. This was unusual because the patient did not have a history of cardiac disease. The GP did not issue a GMS prescription, but instead contacted the hospital ward to make enquiries. It soon became apparent that there had been an administrative error at the hospital and the medications listed on the form related to another patient.
Is the prescription appropriate?
An elderly male patient was diagnosed as having shingles following presentation to the Emergency Department (ED) with a rash and altered sensation. When recommending treatment with aciclovir, the ED physician had forgotten to consider the patient’s history of renal impairment. Hence, the dosage recommended by the ED physician was excessive in the circumstances. The GP, when presented with the hospital prescription form, noted that the patient in question was undergoing long-term renal dialysis and was concerned about the recommended dosage of aciclovir (and, in particular, the increased risk of neurological toxicity). The GP checked a prescribing formulary and issued a prescription for a reduced dosage of aciclovir. The GP also contacted the ED to highlight the case for future learning.
References
- HSE, PCRS handbook for doctors (Information and Administrative Arrangements for General Practitioners), 2006
- Bradley C, Repeat prescribing quick reference guide, ICGP Quality in Practice Committee, 2013
- Medical Council, Guide to Professional Conduct and Ethics for Registered Medical Practitioners, 8th Edition (2016), paragraph 42.5