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Prescribing

Dr Mark Dinwoodie, head of member education at MPS, describes how GPs and nurse prescribers can minimise their risk of making prescribing errors

“Hello…did you mean to prescribe...?”

I suspect most prescribers will have received this call from a pharmacist at least once, if not several times in their career. Prescribing is a complex process complicated by an ageing population, increasing co-morbidity and growing polypharmacy in the challenging environment that is contemporary general practice.

In light of recent publications relating to the optimal use of medicines, now is an opportune time to reflect on some issues and requirements around prescribing and how we might reduce risks to ourselves and our patients from prescribing and medication errors.

Cyril Chantler, Professor of Paediatric Nephrology, said in 1999 that “Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous.”1 While he was referring to healthcare generally, the same can be said of medication.

Context

Prescribing medicines has the potential to alleviate symptoms for patients, as well as to treat and prevent disease or illness. However, it also has the potential to do great harm (as evidenced in Box 1). Harm from medicines may be due to the drug itself or the way they are used by patients or professionals. The interfaces of care are common situations for error and harm to occur, such as the admission and discharge of a patient from hospital.

The medication error iceberg

Medication errors are frequent, however the detection and reporting of them is low. They range from potential errors through unnoticed errors, errors that don’t cause harm (near misses) to errors that cause harm.

One of the challenges is that the same error can cause completely different outcomes according to the setting and context, eg, prescribing a contraindicated drug or the right drug to the wrong patient may not cause any harm, or it could result in severe harm or a patient’s death (see case below).

Prescribing is a good example of the “Swiss cheese” model proposed by James Reason11, representing a combination of individual active errors and latent system errors resulting in error-producing conditions (the holes). As healthcare professionals we are more likely to make errors if certain error-producing conditions exist.

The slices of Swiss cheese represent steps in the process and possible layers of defence. The more layers of defence, the less likelihood that all the holes will line up and harm will occur. These layers of defence will probably be a mixture of individual, system and technological processes. Fortunately, most medication errors don’t cause significant harm, either because the potential for harm is small or one of the defensive barriers (layers of Swiss cheese), such as doublechecking by the pharmacist prevents the error from harming the patient.

There are many facets as to how we manage medicines, resulting from interplay between healthcare professionals, patients and their carers, the medicine itself and the systems we use. Recently the term “Medicines Optimisation” has emerged as a way of trying to focus all these influences and processes on producing the most beneficial outcome for the patient where medicines are involved.

This is particularly the case as polypharmacy becomes increasingly prevalent in an ageing population with multimorbidity and more indications for medicine usage. Polypharmacy can be appropriate or problematic as discussed in a recent review by the King’s Fund.12

Prescribing errors

The GMC-commissioned PRACtICe study conducted in 2012 gives us our most up-to-date and detailed understanding of the prevalence and nature of prescribing errors in general practice.13 Prescribing errors were relatively common with 4.9% of prescriptions containing a prescribing or monitoring error.

One in 500 prescriptions was deemed to contain a serious error. However, with around one billion items being prescribed in general practice in England this year, even a small error rate, if extrapolated, means large numbers of errors with potential episodes of severe harm. (Ie, two million prescriptions with a serious error out of the one billion prescribed annually in England).

Factors contributing to error-producing conditions, as identified in the PRACtICe study could be grouped into seven categories13 (see Box 2).

How can we reduce prescribing errors?

What we are trying to achieve is not only a way to minimise the likelihood of making an error in the first place, but also if we do make an error, that there are enough layers of defence to detect the error or minimise the likelihood of harm occurring. Harm reduction due to errors can be summarised as prevention, capture or mitigation.

Suggested interventions to reduce the risk of prescribing errors:

At an individual level:

  • Therapeutic knowledge and skills especially around multimorbidity and polypharmacy
  • Standardised approach to prescribing, eg, using the MPS PRESCRIBER© checklist
  • Patient involvement
  • Following best practice
  • Medicines optimisation.

Through technology:

  • Ensuring legibility
  • Alerts – eg, monitoring reminders; drug-drug and drugdisease interactions
  • Processes – eg, electronic prescription service.

At an organisational level:

  • A culture that encourages safety and quality in relation to prescribing
  • Safe, effective and efficient systems to enable the optimal use of medicines – eg, repeat prescribing system; drug monitoring
  • Achieving reliable implementation of systems
  • Attention to human factors – eg, minimising distractions and interruptions
  • Reduction in error-producing conditions – eg, removing hazards by separate storage of similar looking drugs
  • Clinical governance – eg, significant event analysis
  • Strategies for higher risk situations – eg, care homes; potentially toxic drugs
  • Use of pharmacists and prescribing advisors as a resource.

Effective communication, particularly around the interfaces of care:

  • Early medication review and reconciliation following hospital discharge.

These issues are addressed in more detail in our three-hour workshop, Medication Errors and Safer Prescribing in Primary Care. It includes the MPS PRESCRIBER© checklist of key tasks, which contributes to the effectiveness and safety of prescribing and helps to ensure that important steps aren’t overlooked, eg, considering whether the patient might be pregnant, checking for drug-disease interactions and arranging monitoring.

Earn CPD points by attending an MPS workshop

All participants who complete a Proof of Attendance form at the workshop will receive a certificate detailing the title of the workshop, date of attendance and duration of the event. The Medication Errors and Safer Prescribing in Primary Care workshop has been certified as conforming to accepted guidelines and is worth three hours of CPD.

The following MPS workshops also have CPD accreditation:

The Mastering series, covering:

  • Adverse Outcomes
  • Professional Interactions
  • Difficult Interactions with Patients
  • Shared Decision Making
  • Mastering Your Risk
  • Medical Records for GPs.

To find out more about our full range of workshops and to book your place, visit our Education pages on the website.

References

  1. Professor Sir Cyril Chantler, The role and education of doctors in the delivery of health care, Lancet, 353:1181 (1999)
  2. Hopf Y, et al, Adverse drug-reaction-related admissions to a hospital in Scotland,Pharm World Sci 30(6):854-862 (2008)
  3. Pirmohamed M, et al, Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients, BMJ, 329:15-19 (2004)
  4. Howard RL, et al, Investigation into the reasons for preventable drug related admissions to a medical admissions unit: observational study, BMJ Quality and Safety, 12(4):280-285 (2003)
  5. Howard RL, et al, Which drugs cause preventable admissions to hospital? A systematic review, British Journal of Clinical Pharmacology, 63:136-47 (2007)
  6. National Reporting and Learning Scheme (NRLS), Quarterly data to December 2013, accessed 18 June 2014
  7. Pickrell L, et al, From hospital admission to discharge: an exploratory study to evaluate seamless care, The Pharmaceutical Journal, 267:650-653 (2001)
  8. Duggan C, et al, Discrepancies in prescribing. Where do they occur? The Pharmaceutical Journal, 256: 65-67 (1996)
  9. Duggan C, et al, Reducing adverse prescribing discrepancies following hospital discharge, International Journal of Pharmacy Practice, 6:77-82 (1998)
  10. Smith L, et al, An investigation of hospital generated pharmaceutical care when patients are discharged from hospital, British Journal of Clinical Pharmacology, 44:163-165 (1997)
  11. Reason J, Managing the risks of Organisational Accidents, Ashgate Publishing Limited (1997)
  12. The King’s Fund, Polypharmacy and medicines optimisation: making it safe and sound, accessed 18 June 2014
  13. Avery T, et al, Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe Study, London: GMC (2012)
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