Dr Rachel Birch, Medical Protection medicolegal consultant and Practice Matters editor-in-chief, answers some recent queries on cosmetic injections and vaccination errors.
“The practice has been approached by the wife of one of our GPs. She is a nurse but has never worked at the practice. She has asked if the GPs can prescribe Botox and filler treatments for a business that she intends to set up. The patients are unlikely to be registered with the practice. Apart from Dr F, who supports his wife’s request, we all have reservations about this proposal.”
In considering the nurse’s request, I would advise the GPs to consider the relevant GMC guidance. Good Medical Practice states that doctors must recognise and work within the limits of their competence and, in providing clinical care, doctors must:
“Prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.”1
Since most of the patients will not be registered with the practice, GPs will not know the patients’ medical history and will be unable to determine whether the treatment is in their best interests. I would suggest the GPs also reflect on the GMC’s prescribing guidance, which states:
“You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate.”2
If a patient suffered an adverse effect of a Botox or filler treatment, a GP could face criticism
If a patient suffered an adverse effect of a Botox or filler treatment, a GP could face criticism and would have to be able to justify why they prescribed the treatment for that particular patient.
Patients may perceive that the doctors are delegating the administration of the prescribed product to the nurse. When doctors delegate treatments to others, they remain responsible for the decision to delegate and must be satisfied that the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient.
The GMC has published specific guidance for doctors offering cosmetic injections. The guidance is clear on the responsibility of doctors as follows:
“You must carry out a physical examination of patients before prescribing injectable cosmetic medicines. You must not therefore prescribe these medicines by telephone, video link, online or at the request of others for patients you have not examined.”3
It is clear that doctors must not prescribe cosmetic injections for patients that they have not examined
It is clear that doctors must not prescribe cosmetic injections for patients that they have not examined.
The practice has been put in a difficult situation and it needs to be handled sensitively, since the requesting nurse is the wife of one of your GPs. However, I would advise that you explain your concerns to her, and suggest that she instead approach a recognised pharmaceutical supplier for the required medicinal products.
“Our practice nurse has given a patient the wrong travel vaccination. How should we handle this situation?”
It is important to act quickly in such a scenario to avoid anxiety on behalf of the patient, as well as avoid a potential complaint. Firstly, talk to the nurse and find out exactly what vaccine was given to the patient and how the adverse event occurred. You should also contact both your local public health team and the vaccine manufacturer to inform them of what happened, and to seek their expert opinion on potential risks and how to minimise them.
As well as the statutory duty of candour for practices, the GMC and NMC also require doctors and nurses to be open and honest with patients if things go wrong. You should provide the patient with an explanation of what has happened, without delay, and offer an appropriate apology.
Revaccination should also be offered, if appropriate
The patient is likely to be distressed, and also concerned about potential short and long term effects. Support should therefore be given, and as much information as possible should be provided. Revaccination should also be offered, if appropriate.
It is a good idea to familiarise yourself with the Health Protection Agency’s vaccine incident guidance.4
Section 6 addresses the risks of administering incorrect vaccines and Section 7 provides information on the risks and benefits of revaccination.
Continual support should be given to the practice nurse, as they are likely to be feeling upset about the incident. As part of this, you may like to offer them further training – and also for any other clinicians undertaking vaccinations.
It would also be worthwhile undertaking a significant event analysis within the practice to investigate in detail how the adverse incident occurred, and what the practice can do to prevent a similar incident happening again. As part of this, you may like to consider developing a practice vaccination protocol that outlines an approved procedure to be followed when administering vaccines. It could also include details of regular stock checks and pre-vaccination checks to be undertaken.
- GMC, Prescribing and managing medicines and devices (2013), para 14
- Ibid, para 55
- GMC, Good Medical Practice (2013) – explanatory guidance: cosmetic interventions, para 11
- Health Protection Agency, Vaccine incident guidance (2011)