Medication errors
Although, strictly speaking, medication errors should come under the heading of clinical management, they account for such a high level of complaints, claims and patient safety incidents that they deserve separate mention. The four most common errors are:
- Wrong dosage
- Inappropriate medication
- Failure to monitor treatment for side-effects and toxicity
- Communication failure between the doctor and patient.
Underlying these are myriad causes (see Box 13). Most of the errors can be avoided by simple checking procedures and clear, open communication.
Weigh up the potential benefits with the risks of drug adverse effects and interactions when deciding what to prescribe
Box 12: Medical Council guidance
“You must ensure as far as possible that any treatment, medication or therapy prescribed for a patient is safe, evidence-based and in the patient’s best interests. You should be particularly careful when prescribing multiple medications in case the combination might cause side effects.
"You should also take particular care when prescribing for patients who may have an impaired ability to metabolise the medication prescribed. You should weigh up the potential benefits with the risks of drug adverse effects and interactions when deciding what to prescribe. This also applies to the exercise of the prescribing of generic drugs. A patient’s treatment regime should be reviewed periodically.”
Medical Council, Guide to Professional Conduct and Ethics for Registered Medical Practitioners (2009) para 59.7.
When writing prescriptions
- Be sure that the treatment is indicated.
- Check that the intended drug is not contraindicated and that the patient does not have a history of adverse reactions to it. Ensure that it will not interact with the patient’s other medication and warn the patient about any potential interactions with over-the-counter remedies.
- If issuing a hand-written prescription, write legibly, taking special care if the drug name could easily be confused with another – use capital letters and give the generic rather than trade name.
- If you use a computer for your prescribing, be aware of the risk of selecting the wrong drug from a drop-down menu (eg, penicillamine instead of penicillin).
- Write clear and unambiguous instructions for dosage, frequency and route of administration.
- Note the prescription and any other relevant information (eg, warnings given to the patient) in the medical record.
- Ensure that the patient is aware of what is being prescribed, and why.
Box 13: Some causes of medication errors
- Badly transcribed instructions
- Illegible prescriptions
- Miscalculation of dosage
- Confusion between similar-sounding drug names or similar-looking packages
- Clicking on the wrong drug in a drop-down menu
- Prescribing contraindicated drugs
- Not checking for potential drug interactions
- Not reviewing repeat prescriptions
- Failure to follow up/monitor
- Failure to act on laboratory results.
Checking procedures
Establish the identity of the patient and double-check the prescription before administering medication
- Be particularly careful when choosing the dose for a drug you are not familiar with.
- If a pharmacist questions a drug order or prescription, check it carefully – many problems are prevented by helpful interaction between colleagues.
- Always read the label on the bottle or vial before administering a drug or other substance, such as water for injection.
- Establish the identity of the patient and double-check the prescription before administering medication.
Communication
- If you are prescribing medication to be administered by other members of the healthcare team, issue clear and unambiguous instructions – answer fully any queries they may have.
- Make sure that your patients understand how to take the medication you prescribe, and that you warn them of any possible serious side-effects or effects that would make driving or operating machinery dangerous.
- If medications are administered on the premises (eg, vaccines or steroid injections) document it (name, time, dose) in the appropriate place in the medical records.
Systems
Even if you already have systems in place, it is worth subjecting them to regular review to see if they’re working as planned or can be improved. This is also an opportunity to remind staff how important it is to follow the procedures laid down.
Important aspects to consider are:
- Reviewing repeat prescriptions
- Printing and signing repeat prescriptions (see the case report below)
- Monitoring toxicity levels (eg, thyroxine)
- Flagging up drug allergies
- Alerting relevant members of the practice (eg, the practice nurse) to prescription changes
- Carrying out a significant event audit when medication errors come to light.