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Mistakes Doctors Do While Writing Prescriptions

Discussion in 'Doctors Cafe' started by Egyptian Doctor, Oct 9, 2012.

  1. Egyptian Doctor

    Egyptian Doctor Moderator Verified Doctor

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    More than one in six patients who are put on medication after seeing their GP are given a prescription containing an error, according to the General Medical Council.


    A study commissioned by the GMC, which regulates doctors, found that over the course of a year, one in 20 prescription items had some sort of error or monitoring of the patient taking the drug was not good enough ”“ this usually involved drugs where regular blood tests were needed to ensure the drug was not causing other problems. With 900m items prescribed in England every year, this amounts to 45m errors. There were also more errors among people over 75, who are often on more drugs.


    Most of the errors fell into the category of oversights rather than mistakes, such as the GP failing to write down how often the patient should take their pills or the correct dose. But in one in 550 items ”“ equating to 1.6m prescription items across England ”“ the error was considered severe.


    "Two were errors where patients had a previous record of an allergy to a drug and were prescribed that drug," said Professor Tony Avery of the University of Nottingham's medical school, who led the research. One was penicillin and the other was an antiviral drug, he said. The allergy should have been flagged up by the practice's computer system.


    Another serious issue was the monitoring of patients, usually elderly, taking the blood-thinning drug warfarin, to ensure they are taking the right dose. If monitoring was supposed to take place outside of the GP surgery, at a specialist clinic, and patients did not turn up, the GP might not know.


    Only one serious adverse reaction was detected among the 15 GP practices from three areas of England selected as representative of the country, which had 1,777 patients among them. An older patient, who was prescribed non-steroidal anti-inflammatory drugs (NSAIDs, which include ibuprofen) was admitted to hospital with stomach bleeding ”“ a known issue with the drugs.


    The study follows a similar GMC exercise in hospitals, which found a prescribing error rate of around 8%. The error rate in GP surgeries is lower, at 5% of items prescribed, and the causes appear to have far more to do with GP-patient interaction.


    "It is quite clear GPs take their prescribing very seriously," said Avery. But one of the problems is distraction. Prescribing takes place at the end of the consultation, when time is running out and sometimes the patient has started to talk about another complaint or problem.


    But the report also shows a delicate relationship between the GP and the assertive or long-term patient who thinks he or she knows best. One GP tried to persuade a patient to come off the contraceptive pill because of her raised risk, but failed, telling the researchers: "She's the kind of patient that knows what she wants and she tells you what she wants".


    One GP said his "hands were tied" by a patient of over 90 who was not taking his warfarin properly but refused to allow the GP to come to his house. Another said he had to compromise with a patient on lithium for mental health problems who refused three-monthly blood tests but agreed to have them every six months. Others, said another GP, "actively change their medication on a regular basis because they think they know best" or don't take it at all.


    Professor Sir Peter Rubin, chair of the GMC, said he will be talking to the department of health, the Royal College of GPs and the Care Quality Commission about ways of improving prescribing.


    "GPs are typically very busy, so we have to ensure they can give prescribing the priority it needs," he said. Effective computer systems could help pick up errors and ensure monitoring and pharmacists could give valuable support and oversight, he added.


    Dr John Holden of the Medical and Dental Defence Union of Scotland said: "MDDUS has dealt with a number of cases where doctors have faced fitness to practise proceedings regarding prescribing errors, many of which could have been easily avoided. In one case a doctor prescribed methotrexate daily instead of weekly to an arthritis patient who became seriously unwell and required hospital treatment.


    "Other complaints relate to drugs that require close monitoring such as anti-depressants being issued as repeat prescriptions without sufficient patient follow-up and monitoring.


    "These errors could have been avoided if robust prescribing systems had been in place to monitor patients and ensure dosage information is accurate."


    The health secretary, Andrew Lansley, said: "Patient safety is paramount. The vast majority of prescriptions are checked by community pharmacists, who spot and put right any errors when they are dispensed. Patients can be confident that the medicines they receive are safe and appropriate.


    "We have worked to improve and increase the training medical students receive in prescribing skills, and we are working with GPs to see how we can best support them to work with pharmacists and improve the safety and effectiveness of prescribing.


    "We will continue to work with pharmacists and GPs to reduce prescribing errors and make the best use of medicines."

    Mistakes in prescriptions.jpg


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  2. neo_star

    neo_star Moderator

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    There is one more aspect which I would like to highlight - lack of coordination between various departments / specialists catering to the same patient.

    Let me give an ex- A patient had come to me seeking advice about Mx of Endometrial carcinoma. I am not an oncologist, but since she is my friend's mom she trusts me to provide her some unbiased / unmotivated advice. She is 5 yrs post menopause and then had sudden bleeding 3 weeks back for which an emergency operation was conducted. According to her reports she underwent B/L salphingoopherectomy and the ovaries were normal ( thereby ruling out the estrogen secreting tumors ), the uterus had poorly differentiated endometroid carcinoma close to the isthmus penetrating less than 1/3 rd thickness. There was no mention of lymph nodes and they asked her to undergo 1 or 2 sittings of radiotherapy ( which according to me is of no use / inadequate). Another issue for me was that the qualifier "poorly differentiated" which can be subjective. In terms of endometrial carcinoma - poorly diff would mean closely packed glands with squamous changes with cellular atypia ( technically called complex atypia ) and good diff would be - large cystic glands lined by simple/columnar epithelium ( technically called simple with no atypia or cystic glandular hyperplasia ).

    So i got her referred to another place for her further Rx and they suggested - Radio + Chemo and when I asked them - why ? they said, LSNV ( lymph node status not verified ). SO I asked them to retrieve the slides from the first hospital and send it to a tertiary center - they did it and the report came back as endometrial cancer invading less than 1/3rd with focal squamous changes ... but it was classified as FIGO stage 3, which is a stage assigned for lymph node spread ( but the LN slides were not send ) and the oncologist wants to play safe by assuming the worst case scenario. SO the patient will have to undergo 28 sittings of radio + chemo (which would include the nasty Doxorubicin )..so this could amount to serious over treatment - somebody who should have a led a normal life after radio ( assuming no spread to LN - becos penetration less than 1/3 rd and only focal squamous changes which would put her in FIGO stage 2 ), now will have serious morbidity from chemo to wipe out a spread based on a very light suspicion. We all know how 'DoxoRubs the heart' - in my opinion the chemo in this case is certainly going to reduce her life span.

    Why such a tragic scenario ?

    Well, the surgeon, pathologist and oncologist were supposed to work like the army, navy and airforce with a common enemy - in this case the suspected endometrial CA. The surgeon who is claiming that she removed the lymph nodes, should have spoken to the pathologist about the LN status ( becos that is central to staging and Mx ). The pathologist who is central to this whole fiasco ( if i may call it so ) is not available for comment and the patient is calling the entire medical profession - 'A Big Scam' and perceives most doctors as 'Morons'. Can we blame her for that.

    I think it's time for some serious introspection, esp at times when the whole world is going through some turmoil. We Are the only people with the right tools to bring some cheer in the hearts and some smile on the faces of an otherwise tormented humanity.

    Everybody is foolish for 5 minutes in a day, Wisdom lies in not crossing that Limit.

    (Y)
     

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