Healthcare providers have a statutory obligation to improve the quality of patient care, ensure patient safety and reduce medical error. Suzanne Creed, clinical risk and education manager, examines the repeat prescribing process; one of the key risks identified as part of the CRSA programme in Ireland, and outlines some strategies to mitigate this risk.

By developing and implementing simple risk management principles, practices can address the risks and may prevent avoidable harm to patients.

Medical Protection has been undertaking clinical risk self assessments (CRSAs) in general practice across the UK and Ireland since 2000. A CRSA is a unique systematic approach used to identify potential risks within a practice and develop practical solutions to mitigate these risks; ultimately improving the quality of patient care and reduce a practice’s exposure to unnecessary risk.

REPEAT PRESCRIPTIONS

Medication errors are the source of about 20% of all litigation occurring in general practice and many of these are preventable.¹

Common specific examples include:

• wrong dose
• inappropriate medication
• failure to monitor for toxicity and side effects.

Repeat prescribing is a deceptively complex process; involving over 20 steps – from the initial decision to prescribe, to the patient finally swallowing the medication.2 Errors can and do arise at any of these steps. It is important, therefore, that practices have robust repeat prescribing systems in place to minimise this potential for harm to patients. This system should be outlined in are peat prescribing policy, thus ensuring consistency throughout the practice. All relevant staff should be appropriately trained in the use of the policy and it should be regularly reviewed.

Patients, practice staff and pharmacists all have a role to play in reducing error. Hospital prescriptions and alterations to medications on hospital discharge letters add a further layer of complexity and an enormous potential for error. Safe repeat prescribing is everyone’s responsibility; however, the legal responsibility lies with the doctor who signs the prescription.

HOW AND WHEN DO YOUR PATIENTS REQUEST THEIR REPEAT PRESCRIPTIONS?

Written requests are preferable to verbal requests, as the opportunity for error is reduced. They should be encouraged and can be facilitated by developing a ‘repeat prescription request form’that can be posted, emailed or delivered in person to the surgery.

Some practices still accept prescriptions by phone. In such instances, the practice should have a designated receptionist to deal with such requests and they should be given protected time in a quiet location to manage these requests.

“Can’t I just wait for the doctor to sign it?” Sound familiar?

Patients need to know how your repeat prescribing system works.Many practices allow a turnaround time of between 48 and 72 hours for repeat prescriptions. This will allow colleagues who work part time or have days off, to prepare prescriptions on their return to work without increasing the workload of their colleagues. Practices should use every available opportunity to educate patients about why it takes time to safely prepare and rigorously check the prescription. The receptionists, pharmacists, GPs,practice website and leaflets should all reinforce your process.

GPs should also discuss and agree with local pharmacists that they will dispense an emergency seven day supply. This is particularly helpful when a patient presents on a Friday evening requesting that their hospital script be transferred to a GMS one.The GP then has adequate time to write and sign the script. It’s really important for others in your team not to undermine this timeframe by suggesting it will be ready ‘later today’.

ENSURING APPROPRIATE CLINICAL REVIEW

How does a clinical review happen at your practice? Is it systematic or on an ‘ad hoc’ opportunistic basis? Synchronising the clinical review and quantity of medication issued is highly convenient for patients and the practice.

A useful strategy is to issue sufficient medications until the next clinical review is due. This will also cut down on the overall number of repeat prescription requests at the practice. Patients requesting medication in advance or after their review date may signify overuse or under use of medication and should be brought to the attention of their own GP.

SIGNING PRESCRIPTIONS

Ideally, the doctor who is signing the prescription should know the patient and check the patient file when performing this task. They must ensure that the medication is appropriate and that all necessary monitoring has been undertaken and results are satisfactory. Consider what happens at your practice when you are absent or on holiday? What process is in place? Although another doctor (including the GP registrar) can sign the prescription, even if they are unfamiliar with a patient, it is not ideal for them to do so.

Primary and secondary care interface – high risk!
What happens to a medication change on a hospital discharge letter? How do you manage prescriptions from hospital consultants – eg the transfer of a private prescription to a GMS? Only the GP should add, delete or amend the patient’s medication record. Doctors should never ask, expect, or allow the secretary to do this.

Medication changes should be made upon receipt of the hospital letter and ideally done by the patient’s own GP. You should consider informing the pharmacists of any alterations to a prescription – eg explicitly writing “Atenolol discontinued”or “Ramipril dose increased” on the script. This may avoid unnecessary phone calls from an astute pharmacist, while enhancing clinical governance.

Uncollected prescriptions
Uncollected prescriptions should be brought to the attention of the prescribing GP, where a relevant note should be entered in the patient’s file. Destruction of uncollected prescriptions should only be undertaken on the advice of the prescribing GP.

LEARNING POINTS

Managing risk in general practice is everyone’s responsibility.It should become part of the everyday activity within the practice and involve both clinical and administrative staff.The whole practice has a part to play in recognising potential risks and mitigating them. Looking closely at existing systems will always bring into view new ways of working, and most importantly, improving patient safety.

REFERENCES

1. Silk N, What Went Wrong in 1,000 Negligence Claims, Health Care Risk Report (2000).
2. NHS National Prescribing Centre (UK). Saving time, helping patients: A good practice guide to quality repeat prescribing (2004).