Common problems

Controlled drugs

Some prescription medicines contain drugs that are controlled under the Misuse of Drugs legislation, eg, benzodiazepine, morphine and pethidine. Legal controls apply to prevent them causing harm or being obtained illegally, and cover how they are stored and prescribed. There are five schedules that classify all controlled medicines and drugs, from Schedule 1 to Schedule 5.

Doctors can prescribe all controlled medicines to treat illness or injury. However, doctors must hold a licence from the Home Office to prescribe some controlled medicines to treat addiction, but it is common to treat addicts with temazepam (Schedule 3), other benzodiazepines (Schedule 4) and methadone.

Problem drugs

While care needs to be taken when prescribing any medication, certain drugs crop up regularly in the GP complaints and claims that MPS sees.

  • Steroids – the most commonly occurring drug in an analysis of GP claims. Problems occur with both oral and topical steroids. Long-term prescribing, and problems with steroid injections, eg, atrophy at the injection site, are the main reasons.
  • Antibiotics – prescribing penicillin or septrin to someone with a known allergy is often the reason for a claim. Problems with prescribing antibiotics, including interactions with other drugs (like warfarin or oral contraceptives) and not prescribing antibiotics, can also lead to complaints and claims.
  • Warfarin – problems with prescribing and monitoring warfarin are common. Interactions with other drugs can be a cause of problems.
  • Lithium – a drug with a narrow therapeutic range, which should not be prescribed unless facilities for monitoring serum lithium levels are available.
  • Diazepam – problems with long-term prescribing.

What is the patient taking?

Watch out for what else the patient is taking. Interactions with medicines are not just limited to prescription-only medicines.

Where relevant, remember to ask about other aspects of the patient’s lifestyle that may have an effect. This might include:

  • Over-the-counter drugs, particularly aspirin and other NSAIDs.
  • Use of alcohol and recreational drugs.
  • Use of herbal medicines, particularly those that have a known interaction, such as St John’s Wort. Patients with chronic conditions may well try different remedies while on their existing medication.
  • Food supplements and diet. For example, cranberry juice is reputed to be beneficial for prostatic infections and UTIs, but interacts with warfarin.

Patients who won’t attend for review

Sometimes, a patient may be on a certain drug on repeat prescription, but will not attend for review or tests, eg, a patient may be taking warfarin to protect a heart valve, but won’t attend for INR blood tests.

This makes it difficult to prescribe safely, but stopping the treatment also has consequences. It may be appropriate to provide the patient with a short supply of medication in order to tide them over until they come into the surgery for a review, stressing the importance of this for their long-term health management.

Numbers and units

  • Decimal points can be easily missed, so do not use them unnecessarily, eg, 5mg not 5.0mg. You can use a decimal where you need to express a range, but always use a zero in front of a decimal eg, 0.5 (not .5) to 1g.
  • Use milligrams, not a decimal of grams, eg, 500mg not 0.5g.
  • Use micrograms, not a decimal of milligrams, eg, 500 micrograms not .5mg.
  • Micrograms and nanograms should not be abbreviated.
  • Do not use cubic centimetre, cm3 or cc. Use ml instead.
  • Directions should be written in full in English. Some Latin abbreviations are acceptable (these are detailed in the BNF).When calculating a dose, ask a colleague to check your calculation, if possible.

Handwritten prescriptions

Although most prescriptions will be printed by the computer, you will still need to handwrite prescriptions, eg, when on a home visit, or out of hours.

A handwritten prescription should:

  • Be written legibly in ink.
  • Be signed and dated.
  • Include the full name and address of the patient, and preferably the age and date of birth (these must be included for children under 12).
  • Have the name of the drug written in block capitals (do not abbreviate).
  • Give clear instructions for the dosage, frequency and method of administration.

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