GMC calls for a national prescription chart to reduce errors

Prescribing errors in hospitals could be reduced if a standardised prescription chart was introduced in all UK hospitals, according to research commissioned by the GMC.

An in-depth study into the causes and prevalence of prescribing errors made by Foundation Year 1 doctors (first year foundation trainees) has found that prescription errors are not solely, or even primarily, a problem of the most junior trainees and that doctors at all levels, including consultants, make mistakes.

The study showed that the causes of the errors, such as miscalculating the dose, were complex and included straightforward human or communication errors that happen in busy and stressful working environments. Some of the errors were as a result of the system the doctor was working in, including complex or unfamiliar prescribing charts.

The report stressed that very few prescribing errors caused harm to patients because almost all were intercepted and corrected before reaching them. The intervention of nurses, senior doctors and, in particular, pharmacists was vital in picking up errors before impacting upon on patients.
The recommendations apply to all doctors and the study concluded that improvements in medical education are only one potential area which could contribute to safer prescribing.

The research team, led by Professor Tim Dornan, checked 124,260 medication orders across 19 hospitals. Of these 11,077 contained errors, an error rate of 8.9%. Of the total orders checked, 50,016 were written by Foundation Year 1 doctors, an error rate of 8.4%. Potentially lethal errors were found in fewer than 2% of erroneous prescriptions.

Errors were classed as:

 • Potentially lethal (2%) 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%) 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%) 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%) 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 Peter Rubin, Chair of the GMC and Professor of Therapeutics, University of Nottingham, said:
“Safely prescribing medicines requires not only an understanding of pharmacology, the science behind how drugs work, but also practical skills such as being able to calculate dosages, correctly fill in quite complex forms and keeping up to date at all times with new drugs and their interactions with existing medicines.

“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. However, all doctors have to remain vigilant to the simple mistakes that can happen as a result of poor communication and busy and stressful working environments. But in addition human error will never be fully eradicated therefore systems must be in place that reduce the likelihood of errors occurring.

“The research is significant as, for the first time, we now have a clear understanding about the causes of prescribing errors in the UK. The recommendations can and should be implemented to make sure that doctors and other health professionals are able to make complex decisions within as simple a process as possible.”

Professor Tim Dornan, Professor of Medicine and Clinical Education and Medical Education Research Group Leader, University of Manchester 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.”

ENDS 

Notes to editors:

The full report can be read here:

http://www.gmc-uk.org/about/research/research_commissioned.asp

Tomorrow's Doctors 2009 is the third edition of guidance first published in 1993. It sets out the GMC's requirements for the knowledge, skills and behaviours that undergraduate medical students should learn, and for the delivery of teaching, learning and assessment. This guidance provides the framework that UK medical schools use to design their own detailed curricula and schemes of assessment.

A press release on this new edition of Tomorrow’s Doctors can be found here:

http://www.gmc-uk.org/news/3266.asp

The guidance can be viewed here:

http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2009.asp

A further study is currently out for tender. This will investigate the causes and prevalence of prescribing errors in general practice.

For further information please contact the Media Relations Office on 020 7189 5454, out of hours 020 7189 5444, fax 020 7189 5401, email press@gmc-uk.org, website http://www.gmc-uk.org.

The General Medical Council registers and licences doctors to practise medicine in the UK. Our purpose is summed up in the phrase: Regulating doctors, Ensuring Good Medical Practice. The law gives us four main functions:
 • keeping up-to-date registers of qualified doctors
 • fostering good medical practice
 • promoting high standards of medical education
 • dealing firmly and fairly with doctors whose fitness to practise is in doubt

©2009 General Medical Council Press Office