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11 November 2011
We are carrying out an evaluation of the Electronic Prescription Service [1] in primary care, with field studies in eight GP practices in England. Our research so far shares many of the findings of the ethnographic study of Deborah Swinglehurst and colleagues published last week on this Journal.
Repeat prescribing in primary care is a socio-technical system where safety is an emergent property of the interplay of people, technology and organisational routines. The system is made to work by the use of computerised controls, pre-set query slips, unwritten protocols and the collaboration of clinicians and experienced clerks who often have been in the practice for years. Trust plays a major part. A GP told us that the intention is to “make the system safe” so that doctors can cope with a large and increasing volume of daily requests.
However there is very little evidence to say how safe this system is, and if there is indeed one way (or many ways) of running repeat prescribing which produces safer outcomes. This is a real concern, considering the relatively large number of preventable drug-related hospital admissions [2] and the frequency of medication errors in care homes for older people [3]. Research is needed to understand the relationship between these systems and error, and to identify safer strategies of prescription management for, at least some, GP practices.
[1] CFHEP004 project: more information on http://www.haps2.bham.ac.uk/publichealth/cfhep/004.shtml and the project website http://www.epsevaluation.org.uk/
[2] Howard RL, Avery AJ, Slavenburg S, Royal S, Pipe G, Lucassen P, Pirmohamed M. (2007) Which drugs cause preventable admissions to hospital? A systematic review 63(2):136-47 http://www.ncbi.nlm.nih.gov/pubmed/16803468
[3] Barber, N D, Alldred, D P Raynor, D K Dickinson, R Garfield, S Jesson, et al. (2009) Care Homes' Use of Medicines Study: Prevalence, Causes and Potential Harm of Medication Errors in Care Homes for Older People. Qual Saf Health Care 18(5): 341-46. http://qualitysafety.bmj.com/content/18/5/341.full
Competing interests: None declared
Information Systems and Innovation Group, London School of Economics and Political Science, Houghton Street, London WC2A 2AE
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7 November 2011
Dear Editor,
This study took place in four fully computerized and organized practices.
The task was easy: repeat prescriptions. How can one mess with that?
We would expect everything to run smoothly and efficiently. But it did not!
Untrained staff decides to "undertake safety checks themselves" because they perceive to have "heavy responsibility" and find "deficiencies in the performance of clinicians"!
"Seeking help from clinicians...we never saw it happen".
"No effective mechanism...clinicians remained largely unaware". [1]
Drug interactions, dosing, length of pharmacological therapy, route of administration, risk of dependency, allergies, etc, should not be overlooked because patients will suffer serious and potentially fatal consequences.
Of course, untrained staff believes "they can pick pharmacology as they go along"! [1]
I was terrified to read that 50% of the requests for repeat prescriptions involved "different items, different names, different doses, different timing" thus leaving all these crucial decisions to that untrained staff!
I can imagine what is happening in less computerized and less automated medical practices, especially when more complex and delicate medical procedures and interventions are involved...
NHS Trusts must realize that they are saving money when employing untrained staff to perform doctor tasks but they risk patients' lives, as this study has clearly demonstrated.
It is unethical to take such high risks. More medical doctors should be employed to better and safer treat patients.
Reference
[1] BMJ 2011; 343:d6788
Competing interests: None declared
Private Sector, 55131
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