Medical Protection Society
Sarah is Staff Writer at the Medical Protection Society, a provider of professional indemnity and expert advice to more than 265,000 doctors, dentists and health professionals worldwide She edits GP Registrar and GP Trainee and writes for Casebook, MPS's member journal, recently reporting on potential pitfalls in expedition medicine and risks associated with medical devices
Prescribing and test results are two of the biggest risk areas for general practices, according to data from the Medical Protection Society (MPS).
Clinical Risk Self Assessments (CRSAs) conducted by MPS in over 100 general practices in the UK in 2009 revealed that more than 94% faced risks related to prescribing and test results, with other high-risk areas including maintaining confidentiality, health and safety, and communication.(1)
Like many risks facing general practices, the effective management of prescribing and test results is threatened by both a lack of systems and processes, and human error.
Pitfalls in prescribing
Many problems with prescribing arise from wrong dose, inappropriate medication and failure to warn of, or recognise, adverse side effects. MPS's analysis of CRSA data identified the risks displayed in Box 1, and Box 2 gives a case study of a typical prescribing pitfall in general practice.
No monitoring of uncollected scripts
Prescriptions that are not collected from the practice or pharmacy should be returned to the GP for review, before destruction. Practices should consider a system to regularly review uncollected repeat prescriptions, to check whether there may be under use or poor compliance with medication, eg, indicating on the patient's records that they have not collected their prescriptions.
Staff generating scripts in reception area
Ideally, repeat prescriptions should be generated by a designated person, in a quiet location where full concentration can be devoted to the task. All staff should be fully trained and understand the importance of the repeat-prescribing process.
No robust repeat-prescribing policy
Thirty-four percent of practices visited during 2009 by MPS did not have a robust repeat-prescribing protocol. If this is the case, the practice should discuss and draw up a comprehensive repeat-prescribing protocol that formalises all the good prescribing systems that take place at the practice. Ensure that all staff are trained in the procedure and have access to the protocol, which should be dated and regularly reviewed.
Clarify patient details
Check the identity of the patient before issuing a drug; beware of similar-named patients. The person collecting the prescription should be asked for details of the patient, ie, name, address and date of birth. Ask the collector to check the prescription before leaving. Keep a record of the collection of controlled drug prescriptions, eg, name of person collecting, time and date.
New patient prescriptions
At 23% of the practices MPS visited, new patient medication lists are passed to the prescription clerk who adds the medications to the computer. A prescription may be generated for a new patient without the patient having seen the doctor for a review of their medication. The additions to the computer are not checked by the doctor. This system is risky, as the patient receives a prescription signed by their new GP who has not undertaken a review of the new patient's medications.
Repeat prescription requests by telephone
Most practices accept repeat-prescription requests by post, fax, tear-off slips from previous repeat scripts and via the internet. However, some practices allow patients to request via the telephone, which is felt to be risky. If telephone requests for repeat prescriptions are to be allowed, ensure that the system is robust and all staff adhere to it.
Prescriptions for drugs prescribed during a home visit are mostly handwritten. These drugs are not always recorded onto the computer, resulting in an incomplete medication history for the patient. The medication should be added to the medication screen, not just in the consultation text, on return to the practice by the GP.
Effective test results systems
Test results can also cause problems for general practices as they involve multidisciplinary team working, and unless recording systems are in place, results may not be flagged or followed up. MPS has identified the most common risks, which are displayed in Box 3.
A typical example of poor follow-up is shown in Box 4. Clearly, there are a number of red flags arising from this scenario.
No tracker system
What may be of concern to the practitioner is that there is no reliable method of checking that the patient has attended his/her follow-up appointment, which may lead to the delay in diagnosis of a clinically significant condition. Practices should consider having a system for the effective tracking of patients considered by the practitioner to require monitoring or follow-up.
No record of tests requested
One of the challenges for practices is ensuring that all samples sent off to the laboratory are returned as results. Requests for tests should always be recorded in the patient's notes. It is the GP's responsibility to check the results once they come in, and act on them. It is a good idea regularly to review your practice's system, perhaps undertaking an audit of "ins and outs" of patient samples to ensure all results are returned to the practice.
Not informing patients of abnormal result
Responsibility for actioning test results lies with the practice – do not assume that a patient will phone up to find out if any action is necessary. It is good practice to have a system for ensuring that the desired action is carried out, eg, a follow-up test, investigation or review, by contacting the patient.
The practice should make every effort to contact the patient and record these attempts. Do not file a result unless it is marked as having been actioned. When a patient has contacted the practice for a result, this should also be noted in their record.
Often, trying to get in touch with patients can cause a test-result headache. Try encouraging patients to keep their contact details up-to-date, eg, through notices, messages on prescriptions, practice leaflets and newsletters. The time of referral or arranging investigations is an ideal time to confirm patient details, particularly their mobile phone number.
Clarify the nature of the test results and the date they were taken. If the call is answered by someone else, or there is an answer phone, simply leave a message asking them to contact the practice, without disclosing any details.
No test list
Sometimes, patients may have multiple tests. If this is the case, the patient should be informed of how many tests will be carried out, perhaps being given a list of the samples that they have had taken (such as a tick box on a pre-printed sheet), along with the usual timescale.
Non-clinical staff entering into clinical discussions with the patient
If asked to contact the patient, administrative staff should not enter into any clinical discussion regarding test results, but simply read out the doctor's comments, which should be clear, informative, and devoid of medical jargon.
If further discussion is needed, a telephone appointment should be made. This prevents the likelihood of a receptionist being asked further questions about the result by the patient. If comments left by the doctor are insufficient, the patient may end up needing to speak to the doctor unnecessarily.
Managing risk in practice
Everyday activities involving both administrative and clinical staff, such as prescribing and test results, pose a great risk in general practices. The whole practice has a part to play in recognising potential risks – and mitigating them. Looking closely at existing systems will always bring into view ways of working differently and, most importantly, improving patient safety.
1. Data referred to is from 126 CRSAs undertaken from January-December 2009.