Errors in prescribing can lead to challenging situations but mistakes do happen. Dr Ben White of Medical Protection has put together some top tips to reduce risks and prevent clinical incidents.

In Omar Alam’s article on making the most of your NHS interview, he recommended a period of shadowing for IMGs taking up a new position in the NHS. If the prescribing process isn’t part of your hospital induction, then we suggest having a colleague or supervisor take you through this during that period of shadowing.

You should familiarise yourself with the GMC guidance, Good Practice in Prescribing and Managing Medicines and Devices. This guidance document states:

“‘Prescribing’ is used to describe many related activities, including:

• supplying prescription-only medicines
• prescribing medicines, devices, dressings and activities, such as exercise
• advising patients on the purchase of over –the-counter medicines and other remedies.”

“It may also be used to describe any written information (information prescriptions) or advice you give to patients.  While some of this guidance is particularly relevant to prescription-only medicines, you should follow it in relation to the other activities you undertake, so far as it is relevant and applicable.

Before prescribing

The GMC’s guidance Good Medical Practice states at paragraph 16 (a) that a doctor should: “Prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health, and are satisfied that the drugs or treatment serve the patient’s needs”

The GMC also states in its guidance “Good Practice in prescribing medicines and devices”, at paragraph 67: “Wherever possible, you must avoid prescribing for yourself or anyone you have a close relationship with.” Further advice on this point is provided in the subsequent paragraphs of the same GMC guidance document.

You must know not allow any financial interests you have to affect the way you prescribe for patients.

Ensure you are familiar with current guidance from the British National Formulary (BNF), including the use, side effects and contraindications of the medicines you are intending to prescribe.

You should also be aware of guidance relating to the clinical and cost-effectiveness of the medicines you are prescribing. This is available from the National institute for Health and Care Excellence (NICE) in England, Wales and Northern Ireland or the Scottish Intercollegiate Guidelines Network (SIGN) in Scotland 

Your local commissioning body or Trust may also have specific prescribing policies and guidance, which you should be aware of and pay close attention to.

It is important to be aware that the person who signs the prescription is the one who will be held accountable, should something go wrong. If you prescribe at the recommendation of a nurse or other healthcare professional, you must be personally satisfied that the prescription is appropriate for the patient concerned. Paragraph 76-78 of the GMC guidance “Good practice in prescribing medicines and devices” provides more information on this topic.

Checking the dosage

Often when e-prescribing there may be a selection of doses to choose from however you should always check that you are prescribing the correct dose of medicine; this includes checking the strength, frequency and route. This is especially important in prescribing for children. Details on dose, contraindications, cautions, side-effects and monitoring etc are available in the BNF.

Checking for contraindications

You need to ensure that the patient:

• is not allergic to the proposed medication
• is not taking any medication (prescription, over-the-counter or alternative medicine) which may interact with the proposed medication
• does not have an illness that may be exacerbated by the medication.

Consent

The principle of informed consent applies as much to the prescribing of medication as it does to the performance of a surgical procedure. Patients should be fully informed about their condition, the reason for recommending the proposed treatment, what they can expect in terms of improvement, symptoms to report, the need for any monitoring and review, and side effects that may occur – including interactions with other drugs, including over-the-counter medicines and alcohol. It is important to highlight to the patient when driving and/or handling dangerous machinery might be contraindicated with certain medications.

Monitoring and follow-up arrangements

You should agree with the patient the appropriate arrangements for follow-up and monitoring. Patients need to know under what circumstances they need to come back, and what the consequences of failing to attend for review could be.

Writing prescriptions

You should familiarise yourself with what is required when writing a prescription either by hand or when dealing with computer generated prescriptions.  The BNF provides guidance on prescription writing here.

There are special rules that apply to the prescribing of controlled drugs and you should ensure you are aware of these.  Further information is provided in the BNF here.

Blank prescription forms should be kept in secure conditions.

Records

A clear record should be made in the patient’s notes of all medicines prescribed.

Continuation of a prescription across care settings

It is common for general practitioners to be asked to continue prescribing a medication started in the secondary care setting.  The GMC guidance “Good practice in prescribing medicines and devices”, at paragraphs 74 – 82 details the considerations when sharing care in this way.

It is important that healthcare professionals are clear who will be undertaking any required monitoring and review of medication. In many areas, Shared Care Guidelines have been established to aid communication and reduce the risk of errors occurring.

Medicines and Healthcare products Regulatory Agency (MHRA)

The MHRA produce regular drug safety updates and it is important to ensure that you are aware of these alerts when they are published.  More information can be found on the MHRA website.

Survival tips…

• Ensure that you are familiar with what is legally required when writing prescriptions
• Be aware of a patient’s drug allergies and any interactions with medications they may already be taking
• Only prescribe drugs to meet the identified need of the patient
• Refer to the British National Formulary (BNF)
• Prescriptions should be written or typed and signed by the prescriber.

Within your medical setting there will be different processes for prescribing for in and out-patients and different forms to get to grips with. We hope you find this guidance useful but, if at any point you are in doubt, ask your mentor or the pharmacist who will be able to guide and advise you.

Further information

GMC Good Practice in Prescribing and Managing Medicines and Devices 

British National Formulary

National Institute of Health and Clinical Excellence

Medicines and Medical Devices Act 2021

Misuse of Drugs Regulations 2001

Medicines and Healthcare Products Regulatory Agency

About the author

Ben White is a Medicolegal Consultant and Team Leader in Medical Protection’s Case Handling team. He was a GP working in Yorkshire for 11 years before moving to Medical Protection in 2016.