It is estimated that every year in the NHS in England 237 million medication errors occur (Elliot et al, 2021); of these 21% are made during the prescribing stage and 38% are in primary care. Prescribing was introduced in legislation for nurses and pharmacists in a stepwise manner, culminating with full independent prescribing rights for nurses in 2006, with an aim of improving patient's access to medicines. The Nursing and Midwifery Council (NMCa) data from March 2021 suggests that 50 693 of the 730 000 NMC nurse registrants are now independent or supplementary prescribers. There is a lack of data specifically on non-medical prescribing error rates in the general practice setting, likely due to the shorter length of time that non-medical prescribers have been in practice, and lack of prescribing error data overall in primary care. This article covers what a prescribing error is, the most common errors and how to investigate and report them.
What is a prescribing error?
The Medicines and Healthcare products Regulatory Agency (MHRA, 2014) defines a medication error as: ‘a patient safety incident where there has been an error in the process of prescribing, preparing, dispensing, administering, monitoring or providing advice on medicines.’ It then goes on to describe two subcategories, namely errors of commission - those that result from an action including prescribing the wrong medicine or dose - and those of omission - where drug monitoring is not performed to ensure the prescription is safe, or a prescription is missed (MHRA, 2014). As a subset of medication errors as a whole, prescribing errors can be defined as those which involve decisions around the treatment, the physical or electronic prescription and follow-up or monitoring. Prescribing errors can also be categorised by the level of harm that results from them; errors spotted before they reach the patient being called ‘near misses’ and those that reach the patient then being divided by the level of potential or actual harm. THe PRACtICe study (Avery et al, 2021), combined three methods to examine prescribing errors in general practice, a systematic review, a retroactive case review (which included examination of 6048 individual prescription items for 1777 patients) and subsequent interviews with prescribers about potential errors, focus groups and numerous root cause analyses. The study identified that around one in eight patients, or one in 20 prescription items, had an error of prescribing or monitoring, with the minority (one in 550 items) being the most severe type.
What are the most common prescribing errors in primary care?
According to the PRACtICe study (Avery et al, 2012), the most frequently found prescribing errors in primary care were those where there was information missing from the prescription. Seemingly in most cases, when reviewing the study's analysis, this was where the reviewer felt that the instruction ‘as directed’ did not give the patient enough information to use the prescribed item safely. Although this type of error was the most frequent, it did not account for any of the severe errors found in the study when a closer look was taken at which level of harm was a result of which type or error. The rest of the ‘top five’ types of errors from the same study (Avery et al, 2012) included dose and strength errors, timing errors, frequency errors and omission errors (failure to prescribe concommitant therapy, such as a proton pump inhibitor with a non-steroidal anti-inflammatory). Grouped separately, Avery et al (2012) reported the most common monitoring error was tests (such as the International Normalised Ratio (INR) for warfarin) not being ordered. In the same study (Avery et al, 2012), a sample of 11 severe errors were examined more closely; of these, nine involved warfarin, and all nine were due to warfarin prescriptions continuing where there had been no blood monitoring for an extended period (in 7 of the cases the last documented INR was over 2 years ago). The other two errors found in the study (Avery et al, 2012) with potential for severe harm were a course of flucloxacillin prescribed for a penicillin allergic patient, and a course of aciclovir prescribed for a patient with a history of severe allergic reaction to it.
‘An open and fair approach to investigating all errors means that causes, trends and contributing factors can be more readily identified and is therefore understood to lead to a safer overall culture in practice.’
It follows that the most common errors do not necessarily cause the most harm. Another systematic review (Bullen et al, 2020) looked at seven papers that considered prescribing error reporting in general practice, and three from community pharmacy, exploring why there are low rates compared to known levels of errors. It concluded that the barriers to prescription error reporting in primary care included a lack of clear definition of a prescribing error, and organisational separation between the pharmacies and general practice. This is in spite of practitioners recognising the value of reporting in terms of the learning and reduced future harms. A paper published by Cousins et al (2019) examined numerous sources to pool data to try and draw together a list of the top ten prescribing errors that are most likely to result in death, severe harm, or medical indemnity claims. The top five were:
- Prescriptions for medicines that were omitted or delayed
- Anticoagulants
- Opioid analgesics
- Insulin
- Non-steroidal anti-inflammatory drugs.
Omitted medicines are particularly important to consider when prescribing in primary care and managing chronic disease; on a small scale they refer to where individual doses are missed or delayed, on a wider scale they are where a treatment is missed altogether from a regime. The Quality and Outcomes Framework (QOF) aims to help avoid such omissions by setting targets for the proportion of patients, for example, on an angiotensin converting enzyme inhibitor (ACEi), which is one of the medicines which would form part of the evidence based ‘set’ a prescriber may expect to see prescribed for a patients with heart failure. Similarly, prescribing systems such as EMIS do also have built in alerts for some of these common errors of omission.
Anticoagulants (including coumarins such as warfarin and direct acting oral anti-coagulants ([DOACS]) are unsurprisingly high on this list, which aligns with data from the PRACtICe study (Avery et al, 2012). The risks of anticoagulation prescribing can be moderated by good local protocols, where if responsibility is shared with a local hospital, roles and responsibilities are well defined. Good patient education is also key to ensuring that the anticoagulants are taken safely.
Interestingly, the PRACtICe study (Avery et al, 2012) also found that with each additional prescription item a patient received in the course of a year, their chance of an error increased. This aligns with current thinking on reducing unnecessary and problematic polypharmacy, which is described in detail in the latest Department of Health review ‘Good for you, good for us, good for everybody. A plan to reduce over prescribing to make patient care better and safer, support the NHS, and reduce carbon emissions’ (Department of Health and Social Care, 2021).
How should errors be investigated and reported?
Firstly, it is important to ensure that if a prescribing error is noted that the patient is cared for and any medical care that they need is dealt with as a matter of priority. If there is any evidence of the error, documentation of this should occur. This is often completed by taking copies of any paperwork or photographing the evidence. The practitioner will have a duty of candour (NMC, 2021b) - this means that they should explain to the patient (or where necessary their carer or advocate) that something has gone wrong, apologise for what has occurred, and where it is in their power they should also offer to remedy the situation. The long- and short-term effects of any error should also be explained where this information is known. The duty of candour also means that the professional should be open and honest with their employer, and relevant organisations involved in investigating such incidents. An open and fair approach to investigating all errors means that causes, trends and contributing factors can be more readily identified and is therefore understood to lead to a safer overall culture in practice.
The Care Quality Commission (CQC, 2021) detail what is expected of organisations in terms of error reporting and incident investigation on their website. Firstly, each organisation should have a policy which details how internal errors would be reported and investigated; many practices now use electronic formats for this. The CQC (2021) recommend that all levels of incident should be reported, including those termed ‘near misses’ where the error was discovered before any harm came to the patient. As a professional it would be prudent to be aware of the content of such policies, and ensure that if there isn't one that this is raised internally. A new derivative of the historic system called the National Reporting and Learning System (NRLS) called ‘Learn from Patient Safety Events’ (LPSE) is now being rolled out in England, as it was identified that general practice were low reporters on NRLS due to their internal systems (which are often still somewhat paper based) for incident reporting or investigation not being added to NRLS. All levels of staff, both clinical and non-clinical, are encouraged to report all patient safety incidents (including prescribing errors) using LPSE, which anonymises reports, and data are then used to identify trends across the system. The CQC myth buster (2021) on safety incident reporting specifically identifies practices with high levels of incident reporting as those with an ‘open and fair’ safety culture. Prescribers in other areas of the UK should review their regions governance procedures and be aware of their local and national reporting systems.
How can errors be avoided?
The PRACtICe study (Avery et al, 2012) identifies numerous factors that can defend against a health professional making a prescribing error, and groups these into three domains:
- Personal prescriber strategies
- Practice-wide strategies
- Health information technology strategies.
Personal prescriber strategies
Personal prescriber strategies suggested by the study included a recommendation that the prescriber ensures they are familiar with the safety features built into their electronic prescribing system; for example, does it give an alert when prescribing a drug which the patient already has a documented allergy to? Where would that appear and how would the prescriber find more detail about the previous allergy? Another prescriber strategy included reading the prescription aloud to allow the practitioner to review their own prescription, but also to check the patient's understanding of what is being given to them. The prescriber may feel self-conscious about doing this the first few times, but it has been suggested to help avoid sound-alike prescription errors.
From personal experience it would also be prudent to ensure that all the human factors that help ensure good concentration are implemented by the professional, including minimising distractions, and ensuring that personal factors such as adequate breaks, rest and nourishment are in place. It is also important that the prescriber feels able to voice their concerns and get support from colleagues, so familiarity with the team and knowing where to get support is important too.
Practice-wide strategies
Practice-wide strategies suggested in the PRACtICe study (Avery et al, 2012) included suggestions about how non-medical staff should be involved in the repeat prescribing process in practices, what training they should be offered and using the system to highlight repeat prescription requests with queries on them. Other suggestions in this domain from the study included having a strong safety culture (to include incident reporting and review) and a formulary to ensure greater familiarity with the products being recommended.
Health information technology strategies
The PRACtICe study (Avery et al, 2012) gives many defences that can be implemented in relation to health information technology. This includes prudent coding of adverse reactions or allergies and using various alerts to highlight, for example, if monitoring is overdue, or a drug interacts with another that is prescribed. Many of these are now embedded in practice since the study was published.
Conclusion
Prescribing errors are a preventable cause of harm to patients and they cost the NHS a significant amount each year (Elliott et al, 2021). It is, at least in part, the prescriber's responsibility to manage and reduce the risk to patients, by ensuring the practice environment is conducive to work that requires concentration, maintaining competence, and ensuring that errors are investigated and reported in a ‘no blame’ manner so that if trends emerge action can be taken to reduce the risk of recurrence. If the worst should happen, it is also important for the practitioner to be aware of how to deal with this situation, including caring for the patient, their duty of candour and local incident management policies.
Key Points
- Prescribing errors are common in general practice
- There are lots of factors that contribute to errors, some are modifiable in favour of error reduction
- Error reporting and open and honest investigation with no blame attributed leads to a safer overall culture in practice
- There is a new national incident reporting system for England, called Learn from Patient Safety Events (LPSE). All general practice staff are encouraged to report all patient safety incidents to this, in addition to reporting internally
Useful resources
- The PRACtICE study: https://tinyurl.com/2p9dpm3h
- NHS. Learn from Patient Safety Events (LPSE) incident reporting system: https://record.learn-from-patient-safety-events.nhs.uk/
- Nursing and Midwifery Council - Duty of candour: https://www.nmc.org.uk/standards/guidance/the-professional-duty-of-candour/read-the-professional-duty-of-candour/
- NHS. Patient safety incident investigation (PSII): https://www.england.nhs.uk/patient-safety/patient-safety-investigation/
Useful resources
- What is the process for reporting errors in your area?
- Consider a prescribing error that you have made, or almost made (near miss):
- How did you deal with the error at the time? Is there anything that you would do differently?
- What system should you have considered reporting the error on?
- Name some common errors that are possible in your scope of practice? How can you avoid them?