Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe study

Synopsis

In 2009 the GMC published research (EQUIP study) which investigated the rates of prescribing errors made by foundation trainees in secondary care.

As a follow-up to this study, the GMC commissioned research to determine the prevalence and nature of prescribing (and monitoring) errors in general practice, and to explore potential defences for mitigating their future occurrence.

The study adopted a mixed methods approach comprising retrospective case note review, depth interviews with prescribers, focus groups with members of the primary healthcare team and root cause analysis.

The study examined 6,048 unique prescription items for 1,777 patients. The research found that 1 in 20 prescription items contained either a prescribing or monitoring error, affecting 1 in 8 patients. Although the majority of errors were judged to be either of mild or moderate severity, 1 in 550 of all prescription items contained an error judged to be ‘severe’.

Factors at a number of levels were identified as contributing to these errors. These included a lack of training in the skill of prescribing, distractions and a failure to fully utilise existing IT solutions for safer prescribing.

The study reaffirmed that problems persist with the transfer of medicines information across the interface between primary and secondary care, and that the reporting of incidents beyond the immediate practice establishment continues to be limited, therefore restricting opportunities for wider learning following adverse events.

The report makes a number of recommendations for improving the safety of prescribing including:

  • Promoting the effective use of clinical computer systems for safe prescribing.
  • Increasing the prominence given to therapeutic knowledge and the skills and attitudes needed for safe prescribing during GP training.
  • Promoting the reporting of adverse prescribing events (and near misses) through national reporting systems.

In addition, the research suggests that pharmacists can play a greater role in mitigating the occurrence of error, through reviewing patients with complex medicines regimens at a practice level, and in identifying and informing the GP of errors at the point of dispensing.

Full Report

Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe study (pdf)

Published 2 May 2012