1. Prescribing Errors in General Practice The PRACtICe Study (2012) GMC Investigating Prevalence and Causes

3. 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”

4. 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

5. 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

6. Factors associated with an increased risk of error male patient aged 64 increased number of items prescribed musculoskeletal, immunosupression & malignancy, skin, eye, ENT, cardiovascular disease, infections smaller practices

7. Factors not associated with an increased risk of error grade of GP acute or repeat prescription

8. 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%)

9. 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

11. Causes of Error The Prescriber The Patient The Team The Working Environment The Task The Computer System The Primary Secondary Care Interface

12. Causes - the Prescriber therapeutic training, drug knowledge and experience knowledge of the patient perception of risk physical and emotional health

13. Causes - Patient & Team patient characteristics complexity of individual case poor communication nurses’ quasi-autonomous role

14. Causes - Environment & Task high workload time pressures distractions and interruptions failure to undertake review monitoring reminder systems

15. 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

17. Defences issuing new prescriptions supporting patient decision making dispensing prescriptions monitoring patients amending prescriptions from outside correspondence processes supporting medicines management

18. 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

19. 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

20. 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

22. 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

23. 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

24. 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