Prescribing errors in hospitals could be reduced if a standardised prescription chart was introduced in all hospitals, the GMC suggested this week.
It comes after research - commissioned by the regulator - reveals that doctors at all levels make prescription mistakes.
The study was prompted by allegations that newly qualified doctors were making a disproportionate number of mistakes. But, when 124,260 medication orders were checked, across 19 hospitals, it was found that 11,077 (or 8.9%) contained errors; the error rate for F1s was 8.4% - similar to that of registrars - while only consultants had a significantly lower rate of 5.9%.
The study shows that the causes of the errors, such as miscalculating the dose, were complex. Some of the errors were due to the system the doctor was working in, including unfamiliar or complex prescribing charts, while others were more straightforward human or communication errors.
Pharmacists often save the day by intercepting and correcting the prescriptions. Senior doctors and nurses also play their part. Consequently, potentially lethal errors were found in fewer than 2% of erroneous prescriptions. Situations included trainees failing to check the patient’s allergies and subsequently prescribing medications which were contraindicated.
Tim Dornan, professor of medicine at the University of Manchester, and research group leader, 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.
“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.”
The GMC recommended that all prescription charts be standardised so that doctors are not confused by the format when they change hospital.
Prof Peter Rubin, chair of the GMC, said: “Prescribing decisions in a hospital setting often have to be made quickly, so it is important that a procedure is as simple as possible to minimise the chance of an error being made.”
Commenting on the study, Dr Karen Roberts, MDU clinical risk manager, said: “Some of the medication errors that we see, such as prescribing a drug to a patient who has a known allergy to it, might be prevented by thorough planning, preparation and communication.”
Read the full study.
Read ten tips on better prescribing.
Tags: Drug errors, Prescribing
