Poor monitoring and processes are responsible for errors in one in 20 GP prescriptions.

One in 20 prescriptions written by GPs in England contains an error, and one in 550 contains a serious error, a large study has found. The prevalence and causes of prescribing errors in general practice study, commissioned by the General Medical Council, shows that it is not doctors’ knowledge about drugs that is responsible for most errors but human factors and process issues. Errors chiefly occur because of problems in the process of prescribing and failure to monitor and review patients adequately. Pharmacists reviewed 6048 prescriptions written for 1777 patients by GPs at 15 general practices in England for errors. Most of the 247 prescribing errors and 55 monitoring errors identified were not serious: 42% were minor, 54% moderate, and 4% severe. The most serious related to failure to adequately monitor warfarin or to prescribe a drug to a patient with a documented allergy to it—the two cases of allergy that occurred involved penicillin and aciclovir. There were nine errors involving warfarin monitoring, eight of which occurred in three patients at the same general practice, where it had been routine to prescribe warfarin without knowledge of the patient’s international normalised ratio (INR). Examples of moderate errors included failure to monitor and review treatment and failure to prescribe gastroprotection to older patients taking long term non-steroidal anti-inflammatory drugs. Overall, one in eight patients had a prescription item with an error, and errors were almost twice as likely among children and elderly people. The proportion was 40% among patients aged 75 years or over, because of the high number of drugs they were taking. Themost common prescribing error was incomplete information, which usually meant unclear or non-specific dosing instructions, such as take “as directed.” These accounted for 30% of the errors. Inaccuracies relating to the dose or strength of the drug accounted for 18% of errors and were particularly prevalent in prescriptions for antibiotics. Incorrect dose timings accounted for another 11% and were a frequent problem with oral and topical antibiotics. Tony Avery of the University of Nottingham’s medical school, who led the research, said, “GPs work under considerable time pressure, with frequent distractions and interruptions, and often the prescribing is squeezed into the end of the consultation. While practices do have a lot of systems in place to try and ensure the safety of the prescribing, sometimes there are gaps in those, and there is scope for making them more robust, particularly to make sure that patients get the necessary blood test monitoring.” He added that although GPs in training gained a lot of experience in prescribing, “very little attention [was given] to the skills associated with safe prescribing.” Furthermore, while computerised prescribing systems reduced error rates overall, their use was actually the cause of some errors. “GPs reported how they might pick the wrong drug or wrong dose of a drug from a drop-down menu,” he said. Peter Rubin, chairman of the GMC, said that there was a “cry wolf” effect with such systems and that they needed to be made “smarter” to highlight only the most serious potential problems. He explained: “Every conceivable drug interaction and every conceivable drug side effect comes up even though the majority of these interactions or side effects are clinically quite trivial. Eventually doctors come to ignore them.” He said that the research identified a number of organisational changes that practices could make to improve the safety of prescribing. These included: • Working with a local pharmacist to track and learn from prescribing errors (Lancet 2012;379:1310-19, doi:10.1016/ S0140-6736(11)61817-5)