Avoiding medication errors in general practice
Suzanne Creed, Clinical Risk and Education Manager at Medical Protection, discusses the nature of medication errors and provides useful risk management tips on how practice nurses and nurse prescribers can ensure they prescribe and administer medication safely
Medication errors remain one of the most common causes of unintended harm to patients.
A medication error can result in serious harm or even a patient’s death. One third of the errors that harm patients occur during the nurse administration phase: administering medication to patients is therefore a high-risk activity.1
Working in general practice can be both demanding and busy. However, when also taking into consideration the number of steps – and often complexity – involved in the medication process, unfortunately things can and do go wrong.
FREQUENCY OF MEDICATION ERRORS
As part of its Clinical Risk Self-Assessment (CRSA) programme, Medical Protection identified potential risks associated with prescribing in 95% of the practices visited during 2016. (See Resources)
Issues relating to prescribing and medication are the second most common reason for Medical Protection to settle a claim on behalf of one of its members, at around 20% of settled claims.2 Medical Protection data shows that the most common prescribing errors involved a contraindicated drug or an incorrect drug (most commonly antibiotics e.g. unsuitable choice for a wound infection), followed by the wrong dose, then selecting the incorrect dose of the correct drug (most commonly opiates). This is similar to the findings of incidents reported to the National Patient Safety Agency, which sites wrong dose, strength or frequency as the commonest incidents.3
Working outside your scope of practice could not only put your patients at risk but also leave you vulnerable to criticism and in breach of your indemnity arrangement. It is therefore important to be aware of the nature of errors that can occur in general practice prescribing.
As said, most errors in general practice relate to providing the wrong dosage, providing inappropriate medication, failing to monitor treatment for side effects and toxicity, and communication failures between the prescriber and the patient. However, other common causes for error include:4
- Poorly transcribed instructions
- Illegible prescriptions
- Miscalculation of dosage
- Confusion between similar sounding drug names or similar packages
- Selecting the wrong drug from a drop down menu
- Prescribing contraindicated drugs
- Not checking for potential interactions
- Not reviewing repeat prescriptions
- Failing to follow up
- Failing to act on test results.
HOW TO AVOID AN ERROR
Having robust systems in place in your practice can help to reduce the likelihood of a medication error occurring, the risk of harm to your patients, and the prospect of a complaint or claim against you. Simple checking of systems and clear, open communication will facilitate this. For example, when writing prescriptions:
- Check that the drug you are prescribing is not contraindicated and that the patient does not have a history of adverse interactions to it.
- Inform the patient of any potential side effects or interactions that could, for instance, make driving or operating machinery hazardous, and make sure they understand how to take the medication.
- When using a computer to generate prescriptions, double check that you don’t select the incorrect drug from the drop down menu (for instance, selecting penacillamine instead of penicillin).
- Write clear, unambiguous instructions for the dose, frequency and route of administration.
- Make comprehensive notes of the prescription and any other relevant advice given to the patient in their medical record.
It is important to be particularly careful when prescribing a drug that you are unfamiliar with or infrequently use, and if a pharmacist or other colleague queries a drug order or prescription, check it carefully as many problems are averted by helpful interactions from colleagues.
Remembering the Five Rs5 can also be a helpful way to ensure correct drug administration:
Right patient – confirm the identity of the patient before administering the drug
Right drug – double check that the drug being administered matches what is prescribed on the patient’s prescription, and always read the label and check the expiry date
Right dose – take care to ensure the correct dose, and avoid using abbreviations and leading decimal points when writing prescriptions (for example, always use ‘0.2 mg’ instead of ‘.2’ mg)
Right route - ensure the correct route of administration (for example, orally, intramuscular or subcutaneously)
Right time – administer the drug at the specified time. Take particular caution with childhood vaccination schedules, travel vaccination programmes and some contraceptives to ensure that the correct time has lapsed between previous administrations and the one you are about to give.
COMMUNICATION
Underpinning all aspects of good patient care is good communication. This is also an essential aspect of reducing medication errors in your practice.
If you are prescribing medication to be administered by other members of the healthcare team, it is important to issue clear, unambiguous instructions and to ensure that you are available to answer any queries they may have. Always clearly document all drug administration and infusions (including the name, time and dose) in the patient’s medical records, and consider alerting relevant members in your team if there are changes to a patient’s prescription.
REVIEWING SYSTEMS
Even if you already have safe prescribing systems in place in your practice, it is advisable to review them regularly to ensure they are working effectively and to identify areas that could be improved upon. Important procedures to consider are those for repeat prescribing, printing and signing of repeat prescriptions, uncollected prescriptions, monitoring of toxicity levels, flagging drug allergies, and carrying out significant event analysis when a medication error (or near miss) occurs.
ACCOUNTABILITY
All registered nurses should be aware of their professional accountability and scope of practice as outlined in the Nursing and Midwifery Code, which requires nurse prescribers to ensure they remain competent and up to date with their knowledge and skills.6 To help with this, the NHS National Prescribing Centre has developed a single competency framework, which aims to assist prescribers to continually improve their performance to ensure safe effective prescribing.7
The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) have also produced joint guidance on the Duty of Candour.8 It is important that you are familiar with this guidance as it sets out professional standards on what nursing staff should do if something relating to patient care goes wrong, and aims to promote openness and honesty with patients, colleagues and employers.
INDEMNITY
It is now a legal requirement for nurses and midwives to hold an indemnity arrangement in order to be registered with the NMC (July 2014).9
It is the professional responsibility of each nurse and midwife to ensure that they have sufficient cover in place which reflects the risks associated with their scope of practice. The cover that they have in place should be relevant to the risks involved in their practice, so that it is sufficient in the event that a claim is successfully made against them.
Please note that nurses who receive complimentary Medical Protection membership through a Medical Protection Practice Xtra group scheme are provided with indemnity-only membership. This indemnity-only membership does not cover for legal advice or representation at, for example, an NMC disciplinary hearing. The nurses covered under this scheme may in addition to the complimentary membership wish to upgrade their membership obtain full indemnity from Medical Protection. For more information and a quotation please call the membership team on Freephone: 0800 561 9000.
RESOURCES
Medical Protection has developed the Medication Errors and Safer Prescribing in Primary Care workshop, which aims to enhance participants’ understanding of errors in the medication process, and provide some practical tips and strategies to help prescribe more safely. Further information can be found here.
Medical Protection Clinical Risk Self-Assessment (CRSA) programme
REFERENCES
1. Cloete L, Reducing medication errors in nursing practice (2015) Nursing Standard. 29,20,50-59.
http://journals.rcni.com/doi/pdfplus/10.7748/ns.29.20.50.e9507
2. Medical Protection Society (September 2011), Casebook, ‘Learning from clinical claims in primary care’,
https://www.medicalprotection.org/docs/default-source/pdfs/casebook-pdfs/ireland-casebook-pdfs/september-2011.pdf
3. NPSA, Safety in doses: Improving the use of medicines in the NHS, ‘Learning from National Reporting 2007’ (September 2009)
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61626
4. Avery et al, Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe study. Commissioned by GMC (2012)
http://www.gmc-uk.org/about/research/12996.asp
5. NHS Professionals; CG3 Guidelines for Administration of Medicines.
https://www.nhsprofessionals.nhs.uk/Download/comms/CG3%20-%20Administration%20of%20Medicine%20Guidelines%20V4%20March%202013.pdf
6. Nursing and Midwifery Council, The code: Professional standards of practice and behaviour for nurses and midwives, (2015) https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
7. National Prescribing Centre, A single competency framework for all prescribers (May 2012) http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single_comp_
framework.pdf
8. The Nursing and Midwifery Council and General Medical Council, Openness and honesty when things go wrong: the professional duty of candour (2015) http://www.gmc-uk.org/DoC_guidance_englsih.pdf_61618688.pdf
9. The Nursing and Midwifery Council, Professional indemnity arrangements (July 2014)
https://www.nmc.org.uk/registration/staying-on-the-register/professional-indemnity-arrangement/
Related articles
View all Articles