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National prescription chart

A national prescription chart would reduce prescribing errors in Foundation Trusts, according to research from the GMC

The introduction of a standardised prescription chart in all UK hospitals would reduce prescribing errors, according to the General Medical Council (GMC).

An in-depth study into the causes and prevalence of prescribing errors made by Foundation Year 1 doctors has revealed that prescription errors are not solely, or even primarily, an issue for the most junior trainees and that doctors at all levels, including consultants, make mistakes.

Some prescribing errors are the result of the system doctors are working within and include complex or unfamiliar prescribing charts, the report states. In addition, the study showed that the causes of errors, such as miscalculating doses, are complex and include straightforward human or communications mistakes that happen in busy and stressful working environments.

The report stressed that very few prescribing errors caused harm to patients because they were intercepted and corrected before reaching them. It stated that the intervention of nurses, senior doctors and, in particular, pharmacists was vital in picking up errors before they had an impact on patients.

A research team, led by Tim Dornan, professor of medicine and clinical education and medical education research group leader, University of Manchester, checked 124,260 medication orders across 19 hospitals. Of these, 11,077 contained errors, an error rate of 8.9 per cent. Of the total orders checked, 50,016 were written by Foundation Year 1 doctors, with an error rate of 8.4 per cent. Potentially lethal errors were found in fewer than 2 per cent of erroneous prescriptions.

Errors were classed as:
• Potentially lethal (2 per cent) an example was cited in the qualitative interviews and occurred when trainees were following instructions given to them by senior doctors, which did not take account of a patient's allergies. In this situation the trainee failed to check the patient's allergies and subsequently prescribed medications which were contraindicated. These types of incidents were rated as potentially lethal although none caused any harm. 

• Potentially serious, (5 per cent) for example the dose prescribed was too low for a patient with serious disease or too high so as to cause a severe toxic reaction. 

• Potentially significant, (53 per cent) for example, errors of omission whereby a patient's regular medication is not prescribed either on admission, during a rewrite and on discharge. 

• Minor, (40 per cent) for example the prescription order was illegible, ambiguous or used non standard abbreviations.

Many of the recommendations support the developments in the revised version of Tomorrow's Doctors published in September. However, the recommendations and findings will also be of interest to managers within the NHS and other healthcare providers.

Professor Dornan, said: "The research shows the complexity of the circumstances in which errors occur and argues against education as a single quick-fix solution. Education can always be improved, but it must be very practically oriented and include all phases of a doctor's career as well as the undergraduate stage. 

"Medicine can learn a lot from other industries, which have really tackled the problems of training practitioners in complex, adaptive skills. The research shows that a 'safety culture' was sometimes absent when it came to prescribing and the working conditions of newly qualified doctors were not always conducive to safe practice. There is still more that can be done to minimise the mistakes that are made in busy hospitals."


3rd December 2009

From: Healthcare


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