The management of repeat prescribingis an area of indisputable risk within

general practice. Over two-thirds of pre-scriptions issued in primary care eachyear are repeats, while a study in 2012by the GMC revealed that there were GPprescribing or monitoring errors found in1 in every 20 prescriptions.1

General practices tend to haveevolved systems that are heavily relianton both their patient IT system and thehuman-user interface. Patient IT systemsdiffer in the way they allow the user toprocess repeats and the safety featuresthat they offer.

Likewise, every practice contains arange of individuals who have varyingdegrees of knowledge, skills and experi-ence, working in different environmentsand team types. As a result, each practicewill have unique risks.

Avoiding prescribing errorsMDDUS (The Medical and Dental DefenceUnion of Scotland) is a medical and den-tal defence organisation providing accessto professional indemnity and expertmedico- and dentolegal advice for doc-tors, dentists and other healthcare pro-fessionals throughout the UK.

At MDDUS, we see patterns associ-ated within claims of negligence eachyear where these systems have failed andcontributed to patient harm. These pat-terns highlight areas of avoidable risk

and, in order to improve the safety of theirrepeat prescribing systems, practicesshould consider including some of the fol-lowing key elements.

Written policyHave a written policy that includes theresponsibilities of each individual associ-ated with each part of the process. Eachuser, including the GPs, should under-stand the risks associated with their roleand the safety features within the patientIT system, and use the system consis-tently. These risks should include humanfactors – considerations such as the min-imising of interruptions and distractionsduring the processing of repeats.

Clinical responsibilityThere should be clinical responsibility forany changes to the repeat prescribingrecord, including adding new medicinesand reconciling the record after dischargefrom secondary care.

In 2010, the National Patient SafetyAgency (NPSA) and NICE reported that30–70 per cent of patients experience a

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Prescriber 19 March 2014 z 25prescriber.co.uk

Repeat prescribing: 10 tipsto develop a safer systemLiz Price

Failure of repeat prescribingsystems can contribute topatient harm. Here, theauthor suggests 10 tips to beincorporated into generalpractice systems to help prevent avoidable risks.

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medication error when their care is trans-ferred.2 Often discharges are illegible andinclude complex changes to a patient’sprescribing regimen.

A Royal Pharmaceutical report in20113 found that the likelihood of anelderly patient leaving hospital on thesame medicines that they were admittedon is less than 10 per cent. In addition,between 28 and 40 per cent of medi-cines are discontinued, 45 per cent ofmedicines are new at discharge and 60per cent of patients have three or moremedicines changed during their stay inhospital.

GMC guidance states that: ‘anychanges to the patient’s medicines arecritically reviewed and quickly incorpo-rated into their record’. If these tasks aredelegated, the GMC guidance states that:‘only staff who are competent to do soprepare repeat prescriptions for authori-sation’. Before delegating, there shouldbe a critical clinical review, with specificdetailed instruction. The system shouldinclude a clinical check after completionto minimise the associated risk.

AccuracyEnsure the information entered for eachscrip is accurate. New items should beprovided in line with the practice’s pre-scribing policy (ie one-monthly or two-monthly scrips) and, where appropriate,to coincide with existing items to increaseefficiency and reduce waste. Review peri-ods should be appropriate for the med-ication type and patient. In the majorityof practices, the review period defaults tosix months; however, a shorter periodmay be appropriate for some medicines.

Accurate information ‘in’ translates toaccurate information ‘out’ and soprompts about early or late requests formedications should be more meaningful.

Monitoring over- and underuse of medicationsFollowing on from the above, the patientIT systems should be used to monitorover- and underuse. This could indicatenonadherence for a variety of reasonsand, for some medications, there is ahigher risk related to this. If necessary,the patient should be asked to come infor a review consultation.

This is backed up by the GMC, whostate specifically that: ‘you should con-sider whether requests for repeat pre-scriptions received earlier or later thanexpected may indicate poor adherence,leading to inadequate therapy or adverseeffects’.4

AllergiesAll known allergies should be coded con-sistently. Many patient IT systems havesafety features that include warnings toprevent prescribing where there is aknown allergy. These are often only effec-tive where the allergy is appropriatelycoded.

Making changesChanges to repeat prescriptions shouldnot be made by hand. The existing scripshould be cancelled, changed and re -issued. When cancelling prescriptions,a reason should be documented in therecord at the time – most systemsprompt for this. In addition, any prescrip-tions issued by hand should be enteredas ‘given’ into the repeat record. This ismost applicable where the prescriberhas seen the patient at home or in anursing home.

Nonrepeat requestsItems requested that are not on therepeat record should be treated with care.Risk can be reduced where a message ispassed to the prescriber to review therequest and provide a scrip themselves ifappropriate. If the task is delegated, theaforementioned GMC guidance appliesand these items should be flagged to the GP signing the prescriptions as non-repeat.

ReviewsMedication reviews should be under-taken appropriately. GMC guidance statesthat: ‘the patient’s condition is monitored,taking account of medicine usage andeffects and that: at each review, youshould confirm that the patient is takingtheir medicines as directed, and checkthat the medicines are still needed, effec-tive and tolerated. This may be particu-larly important following a hospital stay,or changes to medicines following a hos-pital or home visit’.

Uncollected prescriptionsReview uncollected prescriptions beforedestruction. Any prescriptions that are notcollected should be recorded as ‘not col-lected’ on the patient IT system. Thisensures that safety prompts from the sys-tem are as accurate as possible.

Special attention should be given touncollected acute prescriptions as theremay be a risk associated. These shouldbe given back to the prescriber for criticalreview before destruction as it may bethat the patient should be reminded orasked to attend the surgery for furtherreview.

CollectionIt is possible, in most practices, forpatients to collect their own – or anotherperson’s prescription – by simply provid-ing a name and address. Receptionistsshould ensure that other prescriptionsare not visible to the patient or carer,and that they do not disclose to thepatient that a friend or relative’s pre-scription is also awaiting collection with-out prompt.

ConclusionIt is not possible to completely rid a com-plex system of risk. However, by incorpo-rating the tips above into the IT system,GPs should be able to mitigate many ofthe known and avoidable risks andensure the system is more robust, andthereby improve patient safety.

References1. GMC. Investigating the prevalence andcauses of prescribing errors in general prac-tice: The PRACtICe Study. May 2012.http://bit.ly/1bRd9Et.2. Campbell F, et al. A systematic review of theeffectiveness and costeffectiveness of inter-ventions aimed at preventing medication error(medicines reconciliation) at hospital admis-sion. http://bit.ly/1hYy9fm.3. Royal Pharmaceutical Society. Keepingpatients safe when they transfer between careproviders – getting the medicines right. June2012. http://bit.ly/1gGKE9Y.4. GMC. Good practice in prescribing and man-aging medicines and devices. January 2013.http://bit.ly/1hHj2SZ.

Liz Price is a senior risk adviser atMDDUS

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