prescribing errors in general practice the practice study (2012) gmc investigating prevalence and...
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Prescribing Errors in General Practice
The PRACtICe Study (2012) GMCInvestigating Prevalence and Causes
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Definition
• “A prescribing error occurs when, as a result of a prescribing decision or the prescription-writing process, there is an unintentional, significant reduction in the probability of treatment being timely or effective, or increase in the risk of harm when compared to generally accepted practice”
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Methods
• Systematic Review
• Retrospective review of (2%) sample of prescriptions from 15 practices over 12 months
• Interviews with prescribers for 70 potential errors
• 15 root cause analyses
• 6 focus groups
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Results
• >6000 items for nearly 1800 patients
• prescribing / monitoring errors detected for 1 in 8 patients or 1 in 20 prescriptions
• 1 in 550 items severe error
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Factors associated with an increased risk of error
• male patient
• aged <15 or >64
• increased number of items prescribed
• musculoskeletal, immunosupression & malignancy, skin, eye, ENT, cardiovascular disease, infections
• smaller practices
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Factors not associated with an increased risk of error
• grade of GP
• acute or repeat prescription
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Commonest Errors
• incomplete information on the prescription (30%)
• dose/strength errors (17.8%)
• incorrect timing of doses (10.5%)
• failure to request monitoring (69.1%)
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Medicines Reconciliation
• 97% of hospital discharge prescriptions contained an alteration from admission drugs
• 10% of these involved a change in dose (none highlighted)
• 34% of discharge medications were ‘new’ (only 8% highlighted)
• discrepancies occurred in 42% of subsequent GP prescriptions
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Causes of Error
• The Prescriber
• The Patient
• The Team
• The Working Environment
• The Task
• The Computer System
• The Primary Secondary Care Interface
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Causes - the Prescriber
• therapeutic training, drug knowledge and experience
• knowledge of the patient
• perception of risk
• physical and emotional health
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Causes - Patient & Team
• patient characteristics
• complexity of individual case
• poor communication
• nurses’ quasi-autonomous role
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Causes - Environment & Task
• high workload
• time pressures
• distractions and interruptions
• failure to undertake review
• monitoring reminder systems
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Causes - Computing & Interface
• selecting wrong drug or dosage on pick lists
• overriding interaction alerts
• unnecessary/inappropriate alerts
• failure to maintain accurate electronic records
• poor quality correspondence
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Defences
• issuing new prescriptions
• supporting patient decision making
• dispensing prescriptions
• monitoring patients
• amending prescriptions from outside correspondence
• processes supporting medicines management
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Personal Prescriber Strategies
• read aloud printed prescriptions to help check patient understanding and allow prescriber to check accuracy
• clarifying specialist recommendations where these go beyond GP’s comfort zone
• review newly prescribed medications within 6 weeks
• add repeat medications only when patient stable
• confirm important information with patient even when well known to prescriber
• ensuring prescribers are competent to use all important features of e-prescribing and IT support systems
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Key Practice-Wide Strategies
• adopt a formulary to increase familiarity with medicines prescribed
• discourage verbal requests for repeat prescriptions
• invest in non-medical staff training / dedicated team for repeat prescriptions
• schedule blood tests 1 week before reviews / perform face to face medication reviews
• do not delegate responsibility for difficult patients to locums or junior GPs
• update prescribing record within 48 hours of receiving correspondence
• appoint a practice prescribing lead, build a strong safety based culture, based on blame-free communication
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Key Health Technology Strategies
• code allergies in electronic records
• robust alerts for high risk medicines
• provide online access to medicines information, linking directly from clinical computer system
• embed electronic formulary, use it to guide safer choices
• separate drugs with similar names in pick lists
• grade drug interaction alerts and give brief descriptions of interaction problems
• run searches/audits to identify potential errors & patients requiring monitoring (particularly warfarin), use screen alerts to highlight these
• locum induction package to include familiarisation with information technologies available
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Recommendations for GP Training
• greater prominence for therapeutics in curriculum
• educational packages to support prescribing safety and structured medication reviews
• facility in ePortfolio to record educational activities relating to prescribing
• prescribing competence to be part of MRCGP
• support for transition to independent practice
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Recommendations for CPD
• educational package to support reflection on and support for identified learning needs from PRACtICe study
• strategies to support GPs dealing with high risk prescribing scenarios
• strategies to help GPs make best use of prescribing IT
• strategies to improve prescribing safety systems
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Recommendations for Clinical Governance
• conduct audits using prescribing safety indicators and correct problems identified using evidence based approaches
• conduct significant event analyses
• report prescribing adverse events (and near misses) using National Reporting and Learning System
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