Medication Reviews & Repeat Prescribing of Potentially Harmful Drugs

Medication Reviews

Medication and prescribing errors can cause significant patient harm, and thus can lead to complaints and referral to the Practitioner Performance Team (PPT) or GMC. When these complaints are investigated, the PPT will look at the index case, and also at the records of patients who have been prescribed similar drugs by the practitioner. For instance, where a mistake has been made in anti-depressant prescribing, the anti-depressant prescribing for other patients will be reviewed as well as for the original patient.

This process may reveal errors which relate to a particular type of prescribing. In the anti-depressant example, a failure to monitor or review anti-depressant or other psychotropic medications may be highlighted.

Another theme which is sometimes looked at is the process of medication review. The PPT may look to see how often patients are having their medications reviewed, and whether there is a clear process of review recorded in the notes. This is quite easy to audit, as we usually code "medication review" when we do this in practice.

A good medication review will identify that;

• the review has taken place with the patient present, during a consultation
• a review of the appropriateness of the medication has occurred
• a check has been carried out of the compliance and concordance
• the patient’s understanding of the medication has been checked

Of course, in practice, this is not always practicable. This is understood by the PPT, and some allowance is made. However, when a GP has recorded "medication review" without any indication of what this involved, the question is asked whether the prescribing is safe.

Thus, we recommend that, if a medication review is done outside of a consultation, the GP should record the reason and nature of the review. For instance, if a nurse does a chronic disease review, and the GP is then asked to review the medication, this should be annotated in the record, "meds reviewed as per nurse chronic disease review". A simple line in the notes is all that is required.

Repeat Prescribing of Potentially Harmful Drugs

The repeat prescribing of medications is an essential role of general practice, and practices have policies and procedures in place to prevent adverse events happening due to these prescriptions. However, some adverse events are inevitable, due to administrative errors. In most cases, these adverse events have little or no consequence for the patient, as the drugs are not high risk. However, there are certain drugs which do carry more risks, such as; shared care immunosuppressants, opiates, anticoagulants, and antiepileptic drugs, where repeat prescribing errors can cause long term harm.

It is essential that, with these potentially harmful drugs, practices have procedures in place to ensure that prescription errors are minimised.

In one recent performance case, a patient was able to order prescriptions repeatedly for a harmful drug without adequate reviews occurring. This happened due to a technical glitch with the electronic prescribing system in which the computer incorrectly calculated the number of days between prescriptions, thus one month supply could be ordered every two weeks. Because the prescriptions were generated via online request, and there was no restriction on the number of issues the patient could request, the prescription administration team, and the doctors, did not realise that the prescription was being over ordered. This led to a significant adverse outcome.

Following this case, the practice identified a number of cases where this had occurred, and has made changes to their prescribing of these drugs. The practice now restricts the number of repeat prescriptions which can be ordered, without reauthorisation, to three. Thus, if the drug is requested too frequently this becomes easily highlighted.

The LMC thus recommends that-

• for drugs which have potentially significantly harmful effects if taken in excess, practices should restrict the potential number of prescriptions which a patient can order, so that regular medication reviews are facilitated
• because of the identified glitch in the electronic prescribing systems, the quantity and frequency of these medications should be reviewed when medications are re-authorised