Medicolegal issues: Safe prescribing for nurses

Ten years ago, nurse prescribing was heavily restricted, yet now nurses are able to prescribe all of the drugs in the BNF. So how do nurse prescribers ensure that they are prescribing safely and within their level of competence? Diane Baylis, a registered nurse and Clinical Risk Manager at the Medical Protection Society (MPS), explores some of the pitfalls.

Nurse and midwife prescribing is now widespread practice, with approximately 54,000 nurse and midwife prescribers across the UK.¹ Independent nurse prescribers in the UK, who hold a registered prescribing qualification, can prescribe from the same list of medicines as doctors, within their speciality and competence. And with the amendments to the Misuse of Drugs Regulations 2001, which came into effect in April 2012, nurses are now able to prescribe a wider variety of controlled drugs.²

MEDICATION ERRORS

There is a paucity of research into prescribing errors by nurses, however in the experience of the Medical Protection Society (MPS), the most common issues involve:

• An increased dose of medication being prescribed by a nurse without reviewing the patient and the patient subsequently having an adverse reaction.
• Prescribing in the presence of an allergy (penicillin to a penicillin-allergic patient is the most common example).
• Choosing the wrong drug from a computer-generated selection list.

Nurses should be aware of the nature of errors in GP prescribing to help to reduce their own risk of error. Medication or prescription errors are the second most frequent reason that MPS settles a claim on behalf of its members in general practice.³ Failure to recognise or warn the patient about side effects is the most common error. Claims relating to wrong injections, incorrect or inappropriate prescribing, interactions and wrong doses are also common.

In a recent study undertaken by the General Medical Council looking at the causes and prevalence of prescribing errors, it was reported that one in 20 prescriptions written by GPs in England contains an error. Errors were found to be almost twice as likely in children and the elderly, with the most common prescribing error being unclear or non-specific dosing instructions.⁴

Most medication errors and near misses go un-noticed, often only those that actually cause harm are reported to the trust.

HIGH RISK AREAS

There are certain circumstances when the nurse should use caution; these are the high risk areas where errors are more likely to occur. Two examples are provided below:

1. Prescribing for young children

Prescribing for young children can often present as a challenge. Errors in calculations can occur leading to incorrect dosage, particularly with paediatric doses. This is an area where the nurse may feel under pressure and outside their scope of practice or beyond their competency level, especially if they have not had specific paediatric training. If unsure, a nurse should confirm the dose with a colleague.

When writing a prescription, the British National Formulary (BNF) for children states that 'Inclusion of age is a legal requirement in the case of prescription-only medicines for children under 12 years of age, but it is preferable to state the age for all prescriptions for children. It is particularly important to state the strengths of capsules or tablets'.⁵ The nurse should write the exact dose in weight or - if liquid - the volume required. It is also safer to write the words instead of using abbreviations.

Example of incorrect prescription

Amoxicillin 5ml TDS

Corrrect/Recommended prescription

Amoxicillin oral suspension 125 mg/5ml

125mg three times daily.

It is particularly important that nurses make sure that the parent or carer fully understands the dosing instructions for the medication, how to store it, common side-effects and how to recognise an adverse reaction.

2. Elderly patients

When prescribing for elderly patients, drug interactions and contraindicated drugs are common issues. Elderly patients are more likely to be taking multiple medications; according to the Department of Health four in five people over 75 years of age take at least one prescribed medicine, with 36% taking four or more medicines.⁶ Particular care must be taken to check for potential drug interactions, allergies and previous adverse drug reactions. Fifty per cent of older people may not be taking their medicines as intended so careful explanation and additional time may be required to ensure that the patient understands the dosage, reasons for the medications and that they give informed consent.⁶

COMMUNICATION

Poor communication and documentation can contribute to prescribing problems and therefore detailed, accurate and up to date medical records are vital. It is also important that the patient is advised how to take the medication, in a way they can easily understand, as well as being fully informed about any potential risks or side effects. The National Prescribing Centre (NPC) encourages the use of decision aids to support the decision making process for the patient.⁷

PROFESSIONAL ACCOUNTABILITY

General practice is a demanding and busy environment. Nurses may feel under pressure to work outside their scope of practice which could put themselves, and their patients, at risk. It is therefore important that practice nurses, who are prescribers, work within the limits of their competence.

Nurses are professionally accountable to the Nursing and Midwifery Council (NMC), as well as having a contractual accountability to their employer. In line with the NMC's code, nurse prescribers have a duty to ensure that they remain competent and up to date with their knowledge and skills.⁸ The NPC has recently developed a single competency framework for all prescribers and this will help the nurse prescriber to identify strengths and developmental areas.⁹

Recent changes to the Royal College of Nursing's membership scheme mean that professional indemnity is no longer a benefit.¹⁰ Therefore all nurse prescribers are advised to ensure that they have adequate and appropriate indemnity either through their GP practice or personally, in their own right.

CLINICAL SUPERVISION

Ongoing support from clinical managers aids the nurse's own professional development and ensures that practice nurses receive appropriate supervision. It is also important for the nurse to have the opportunity to reflect on their patient consultations and the prescribing of medication, focusing on what went well and what could be improved.

SUMMARY

No longer do the nurse and patient have to wait for the GP to finish their consultations to sign a prescription. Evidence suggests that nurse prescribing has improved patient care and access - leading to increased patient satisfaction.¹¹

Nurse prescribing was introduced into general practice at a slow pace, but it was a huge step forward for the profession. As the healthcare environment becomes more challenging and complex, nurse prescribers are integral to the ongoing NHS reforms and play a key part in the smooth and cost efficient running of a GP practice. They can do this by taking a systematic and methodical approach, thereby ensuring safe prescribing.

REFERENCES

1. Nursing and Midwifery Council (2010) Statistics in Nurse and midwife prescribing http://www.nmc-uk.org/About-us/Policy-and-public-affairs/Politics-and-parliament/Policy-areas/ 2. Department of Health (2012) Nurse and pharmacist independent prescribing changes announced
http://www.dh.gov.uk/health/2012/04/prescribing-change/ 3. Medical Protection Society (2011) Learning from clinical claims, MPS casebook, volume 19 no. 3, September 2011
http://www.medicalprotection.org/mps-uk-casebook-sept11.pdf 4. General Medical Council (2009) Investigating the Prevalence and Causes of Prescribing Errors in General Practice: The PRACtICe Study
http://www.gmc-uk.org/about/research/12996.asp 5. BNF for Children no 63 March 2012
http://www.medicinescomplete.com/mc/bnf/current/29440.htm 6. Department of Health (2001). Medicines and older people. Implementing medicines related aspects of the NSF for older people
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4067247.pdf 7. National Prescribing Centre. Patient Decision Aids http://www.npc.nhs.uk/patient_decision_aids/pda.php 8. Nursing and Midwifery Council (2008) The code: Standards of conduct, performance and ethics for nurses and midwives
http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/ 9. National Prescribing Centre (May 2012) A single competency framework for all prescribers
http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single_comp_framework.pdf 10. Royal College of Nursing. Changes to the RCN indemnity scheme: your questions answered
www.rcn.org.uk/support/legal/changes_to_indemnity_scheme_january_2012
11. National Prescribing Centre (2010) Non-medical prescribing, a quick guide for commissioners March 2010
http://www.npc.nhs.uk/non_medical/resources/NMP_QuickGuide.pdf