PILLS - Prescribing errors

Preventing prescribing errors

10 Top Tips for Safe Prescribing
1. Keep yourself up-to-date in your knowledge of therapeutics, especially for the conditions you see commonly
2. Before prescribing, make sure you have all the information you need about the patient, including co-morbidities and allergies
3. Before prescribing, make sure you have all the information you need about the drug(s) you are considering prescribing, including side-effects and interactions
4. Sometimes the risks of prescribing outweigh the benefits and so before prescribing think: ‘Do I need to prescribe this drug at all?’
5. Check computerised alerts in case you have missed an important interaction or drug allergy
6. Always actively check prescriptions for errors before signing them
7. Involve patients in prescribing decisions and give them the information they need in order to take the medicine as prescribed, to recognise important side-effects and to know when to return for monitoring and/or review
8. Have systems in place for ensuring that patients receive essential laboratory test monitoring for the drugs they are taking, and that they are reviewed at appropriate intervals
9. Make sure that high levels of safety are built into your repeat prescribing system
10. Make sure you have safe and effective ways of communicating medicines information between primary and secondary care, and acting on medication changes suggested/initiated by secondary care clinicians

Source: NPC/NICE 2011, Professor Tony Avery

Avoiding slips and lapses

Avoiding slips and lapses is difficult, as by their nature, you do not know you have committed them. The risk increases when error producing conditions such as fatigue, stress and a high workload are present. Being vigilant when you know you are tired stressed or overworked and double-checking your prescribing (preferably with another healthcare professional) can help avoid them. It is especially important to double-check your prescribing when dealing with high-risk medicines (e.g. anticoagulants, insulins, opiates, chemotherapy), intravenous preparations and when completing drug calculations. Interruptions can lead to slips and lapses; if possible, try to find a quiet place to work on complex prescribing tasks and ask not to be interrupted. If you are interrupted, be vigilant for slips and lapses when you return to your task.

Avoiding violations

It is crucial that your prescribing is legible and unambiguous to ensure safe prescribing so that the right patient receives the right medication at the right dose at the right time and by the right route. In primary care, the legibility of prescriptions has been improved by the introduction of computer prescribing. However, occasions do arise where handwritten prescriptions are still necessary in the community. In secondary care, electronic prescribing has been introduced in many hospitals for discharge prescriptions, but drug charts are usually handwritten. Common violations include not completing the prescription with sufficient detail for safe dispensing and administration, not documenting allergies, abbreviating drug names and abbreviating dosage units. It can be tempting when you have a high workload to take such short cuts, however the consequences can be catastrophic.

Build good relationships with your colleagues

One of the main defences in detecting errors is other healthcare professionals, particularly pharmacists and nurses. However, there is a tendency for junior doctors to rely on pharmacists and nurses to identify errors (Dornan et al, 2009) and this complacency can potentially lead to serious events.

Speak with your patients

Your patients and their relatives/carers are often the experts on their medicines and are the last line of defence in detecting errors. Educating patients about their medicines and asking them about side-effects and any concerns that they have, can lead to the identification of errors.

Regularly review medicines

Conducting regular medication reviews and ongoing monitoring of treatment is important to ensure that the continued prescription is still appropriate. You may find that your patients receive medication reviews form pharmacists and nurses in the community. You as a prescriber can refer patients for such reviews.

Utilise guidelines for safe prescribing

Your own workplace may have developed specific guidelines for the process of writing prescriptions and for making good choices about medication.

Theophylline

Mr T was receiving Uniphyllin Continus® (modified release theophylline) 400mg twice daily and developed an acute exacerbation of chronic obstructive pulmonary disease. Ciprofloxacin 500 mg twice daily was prescribed by the GP.
What could be the potential consequence of this?
What type of active failure is this?
How could this have been prevented?

Case study
Ciprofloxacin increases the plasma concentration of theophylline (you can find this in the BNF) and this can lead to theophylline toxicity. For example, Mr. T could develop a supraventricular arrhythmia and convulsions.
The active failure is a knowledge-based mistake
This could have been prevented by knowing your drug interactions (see chapter 8). The dose of theophylline could have been reduced or an alternative non-interacting antibiotic prescribed.