Prescribing medication is an entirely commonplace part of daily medical practice. GPs may sign dozens of prescriptions for hundreds of medications each day, while doctors working in secondary care may, as a matter of routine, prescribe drugs that might be particularly liable to cause significant side effects or require monitoring to reduce the risk of doing so.
All drugs have the potential to cause harm, even if prescribed, dispensed and administered correctly. Side effects may be more common if two or more drugs are taken, with the potential for interactions as well as individual side effects, and in our experience, prescription errors are one of the most common subjects for an adverse event or claim.
The following fictional scenario illustrates the sort situation members might face as a result of a digital prescription error.
An MDU member called the medico-legal helpline. Several months previously, he had seen a 47-year old patient with menopausal symptoms. He carried out a thorough clinical assessment, and arranged for some further investigations, including serum FSH testing.
During a telephone follow-up, and after discussing treatment options, he prescribed HRT and the electronic prescription was sent to the patient's preferred pharmacy. Unfortunately, he inadvertently selected an oestrogen-only preparation, from the drop-down menu. The patient had an intact uterus.
Sometime later the patient presented with post-menopausal vaginal bleeding, which required further hospital investigation. No malignancy was found, and the patient was changed to a more appropriate form of HRT. The doctor was concerned about the possible implications of his error.
The GMC has published guidance on Good practice in prescribing and managing medicines and devices, which reminds doctors of their professional and ethical responsibilities in this area. This guidance, and the possible problems outlined above, apply whatever system is being used to prescribe including digital, or electronic, prescribing.
One of the possible benefits of electronic prescriptions, described by NHS Digital, is that, "during face-to-face, telephone or video consultations, prescriptions can be sent to the patient's nominated pharmacy, reducing footfall in the practice as patients collect their prescription from the pharmacy instead".
While this may have been beneficial since the inception of the system, it may be particularly so during the COVID-19 pandemic, and in the future as changes in how we work as a result of the pandemic become 'the new normal'.
There may be benefits to adopting a fully electronic prescribing system, but it is also important to bear in mind the potential problems associated with any prescribing system. Perhaps the most likely of these is selecting the wrong drug (due to them having similar names - for example, chlorphenamine and chlorpromazine), the wrong dose or the wrong frequency from a drop down menu.
With traditional hard copy prescriptions, even when they are computer generated, the fact that a doctor has to physically sign the prescription means that there is one final opportunity to check it before it is given to the patient. After that point, the doctor will have little or no control over what happens, unless the dispensing pharmacist happens to spot a possible error and queries it.
This final safety check may not be a feature of electronic systems, particularly if the patient has nominated a chemist and the prescription is being sent on the spine. The same is true of electronic repeat prescriptions, where there may be no check by a doctor if a number of issues have been authorised.
In 2019, the Healthcare Safety Investigation Branch identified a significant safety risk posed by poorly implemented electronic prescribing systems. Also in 2019, a coroner expressed concerns that peculiarities associated with an electronic prescribing system might put patients at risk.
Back to the scenario…
The MDU advised that the doctor should be open and transparent about his prescribing error and should apologise, in line with the professional duty of candour. Given that the patient had required in-patient investigation, and had experienced significant anxiety before being reassured that there was no malignancy, the GP was also advised to consider whether the statutory duty of candour might apply in this case. The GP was encouraged to discuss the case with colleagues in the context of a formal significant event review, and to ensure that any learning points were acted on.
The patient was grateful for the open approach taken by the GP, and didn't pursue the matter any further.
Electronic prescribing is a relatively recent innovation, and one which is likely to be adopted more widely in future. Changing practices arising from the COVID-19 pandemic and the need to work remotely more often than before may have an impact on this.
While it does have benefits, as described by NHS Digital, it is important to ensure - as with all prescribing systems - that appropriate checks take place when prescribing medication to make sure that each prescription issued is what was intended.
Dr Edward Farnan
MB BCh BAO LLM FRCGP DGM DCH DRCOG
Dr Farnan graduated from Queen's University, Belfast, in 1995 and completed his GP training in Northern Ireland, practising as a principal in general practice in Armagh for 11 years. He also sat on a research ethics committee, and had a particular interest in clinical governance.
See more by Dr Edward Farnan