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Medications – A prescription for risk

Post date: 30/11/2017 | Time to read article: 5 mins

The information within this article was correct at the time of publishing. Last updated 21/03/2019

Medicines are the most common therapeutic intervention in the NHS, but they can also be a significant cause of unintended harm. We hear from NHS Improvement’s National Reporting and Learning System (NRLS) on these risks, and offer some tips on how to stay safe

The Risks

Sabina Khanom, patient safety policy lead (primary care) and Dr Martyn Diaper, patient safety expert adviser in general practice, NHS Improvement

Medicines-related patient safety incidents include medication errors and preventable adverse events. Medication errors can be divided into:

  • errors of commission, including wrong medicines or wrong dose
  • errors of omission, such as failure to prescribe medication when clinically indicated, omitted doses or failure to monitor.

A search of the NRLS for medication-related incidents reported to have occurred in general practice between 1 March 2016 and 28 February 2017, and sent to the NRLS on or before 13 June 2017, highlighted 2,787 incidents. The vast majority (89.9%) were reported as causing no or low harm, but 1.4% were reported as causing death or severe harm. Because of the complexity of the patients’ underlying conditions, not all incidents reported as death and severe harm suggested problems with medication were ultimately the cause of death or severe harm, although they may have contributed to the harm.

The largest proportion of reported medication-related incidents occurred at the prescribing stage (39%, or 1,077). This may be because GPs and GP registrars are the largest group using the GP e-form, and prescribing is the most frequent stage that they undertake in the medication process. 

Medication process

Total

Prescribing

1,077

Administration/supply of a medicine from a clinical area

576

Preparation of medicines in all locations/dispensing in a pharmacy

526

Other

268

Monitoring/follow-up of medicine use

253

Advice

72

Supply or use of over-the-counter (OTC) medicine

15

Total

2,787

The top five categories of reported medication error occurring at the prescribing stage, with illustrative short case studies, include:

  • wrong/unclear dose or strength

An elderly man was started on MST (morphine) 60mg, twice a day, for chronic back pain as an initial dose. Before this he was taking tramadol 50mg, three times a day, for analgesia. After taking four doses of MST he was confused, hallucinating and drowsy. The patient was admitted to hospital, where he received naloxone. 

  • wrong drug/medicine

After a consultation with a COPD patient in the outpatient respiratory clinic, the consultant wrote to the practice requesting the GP prescribe a ‘LAMA’ inhaler. The GP, unfamiliar with this abbreviation, prescribed a salmeterol inhaler (a long acting beta agonist, a LABA). When another GP saw the patient a few months later, the error was identified and the inhaler changed to a tiotropium inhaler (a long-acting muscarinic antagonist, a LAMA). 

  • contraindications to the use of the medicine in relation to drugs or conditions

A patient requested a further supply of naproxen tablets. When authorising the prescription, the GP noticed the patient was on the maximum dose of etodolac, and had had several prescriptions over the last year for additional naproxen to manage chronic pain. The patient had therefore been on two types of NSAIDs at maximum doses at the same time. 

  • wrong quantity

An elderly patient attended the practice, accompanied by his carer, and after assessment the GP prescribed antibiotics. On a routine visit three weeks later, the district nurse noted that the patient was still taking this antibiotic treatment. The district nurse contacted the GP for advice and was told the patient was only to receive one week’s course. However, the patient had been prescribed a month’s supply. 

  • mismatching between patient and medicine

A blank prescription was printed off the computer system by one of the GPs to use when visiting a housebound patient. The visits allocated to the GPs were altered, but the GP used the blank prescription for another patient although it contained the wrong details. The pharmacy noticed this and notified the surgery.

How to manage the risks

Julie Price, Medical Protection head of risk management and education consultancy, describes the use of a checklist for safer prescribing 

Many GPs, pharmacists and nurse practitioners/practice nurses will be aware of how frequently medication errors occur. While many errors fortunately do not result in patient harm, a medication error can result in serious harm or a patient’s death.

Why do errors occur?

Like many risks in general practice, the prescribing process is threatened by both a lack of robust systems and human error, eg, tiredness, stress, interruptions and lack of training. Well-designed prescribing systems can trap human errors and help reduce the likelihood of adverse events, thus preventing harm to patients.

The GMC-commissioned report The PRACtICe Study, which looked at prescribing errors in general practice, identified seven main conditions for prescribing errors. These include the working environment, a patient’s characteristics and IT issues.

Using a checklist

As prescribing medication is a complex and challenging process, it may be useful for clinicians to use a checklist to ensure important prescribing tasks aren’t overlooked. Checklists are routinely used in high-reliability organisations, such as aviation and more recently in healthcare, eg, the WHO preoperative surgical checklist.

In 2008, the World Health Organisation (WHO) piloted a safer surgery checklist, encouraging theatre teams to consistently apply safety checks to all patients, and improving teamwork and communication across hospitals in eight countries.

Results from this pilot showed:

  1. Major complications for surgical patients in all eight hospitals fell by 36%
  2. Deaths fell by 47%
  3. Infections fell by almost half
  4. Using the checklist had spared more than 150 people from harm and 27 from death.

Medical Protection PRESCRIBER© checklist

So using a checklist can reduce harm. With this in mind Medical Protection have developed a simple checklist – PRESCRIBER© – which contributes to the effectiveness and safety of prescribing. You may not wish to use this framework systematically for every prescription but it can be useful as a tool with high-risk patients and settings.

In summary

Medication errors are common and they are often due to individual error, compounded by error-producing conditions and latent system failures. Some drugs are more commonly involved and some aspects of medicines management are at a higher risk of medication errors.

Using a simple checklist may assist clinicians to prescribe safely, reducing the risk of medication errors and harm to patients.

MEDICAL PROTECTION “PRESCRIBER” CHECKLIST

  • Other prescribed medication
  • Hospital prescribed medication
  • Over The Counter (OTC) products
  • Alternative medication, eg, herbal
  • Dietary factors, eg, grapefruit juice (statins), cranberry juice (warfarin)

PATIENT

  • Correct patient
  • Correct record
  • Up-to-date medical information, eg, allergies, co-morbidity

REASON

  • Patient's best interest
  • Evidence-based or consistent with guidelines
  • Appropriate indication/need
  • Benefits outweigh risks
  • Be able to justify your reason for use of unlicensed drugs

EXPLAIN

  • Risk/benefits
  • Side effects
  • Information, including how to take, when to stop
  • Duration of treatment

SHARED DECISION MAKING

  • Consideration of alternatives
  • Answer questions
  • Consider decision aids
  • Reach agreement

CONTRAINDICATIONS

  • Cautions and contraindications
  • Special considerations, eg, pregnancy, lactation or trying to conceive
  • Allergies, intolerances or adverse drug reactions

RENAL & OTHER CO-MORBIDITY

  • Past and present medical history
  • Renal or hepatic impairment
  • Elderly, frail or physical impairment
  • Learning disabilities or cognitive impairment
  • Lifestyle: alcohol, recreational drugs

INTERACTIONS

BNF

  • Use the local formulary
  • Select appropriate drug, dose, strength, frequency, formulation, duration and quantity
  • Look up unfamiliar drugs
  • Check paediatric doses:
    • Include child’s weight and dose per kilogram where appropriate
    • Involve parents
    • Consider confirming calculations with a colleague

EXAMINE PRESCRIPTION

  • Double check prescription before giving to patient
  • Legible if handwritten
  • Avoid "As directed"
  • Specify minimum time interval for "as required" drugs
  • Ensure controlled drugs prescriptions comply with regulations
  • Re-check and read out before handing the script to the patient or sending via EPS

REVIEW

  • Check patient understanding
  • Encourage adherence
  • Confirm monitoring arrangements
  • Follow-up and safety-net
  • Document discussion, eg:
    • Options and alternatives to medication
    • Patient agreement and specific concerns
    • Important questions answered
    • Side effects/benefits
    • Specific advice, eg, how to take, when to stop
    • Planned review and monitoring arrangements

Further information

NRLS reporting e-form: https://report.nrls.nhs.uk/GP_eForm

Patient safety alerts from NHS Improvement: https://improvement.nhs.uk/resources/patient-safety-alerts/

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