Prescription errors in the National Health Services, time to change practice

Abstract

Introduction: Medication error is a major source of iatrogenic illness. Error in prescription is the most common form of avoidable medication error. We present our study, performed at two, UK, National Health Services Hospitals.

Material and methods: The prescription practice of junior doctor's working on general medical and surgical wards in National Health Service District General and University Teaching Hospitals in the UK was reviewed. Practice was assessed against standard hospital prescription charts, developed in accordance with local pharmacy guidance.

Results: A total of 407 prescription charts were reviewed in both initial audit and re-audit one year later. In the District General Hospital, documentation of allergy, weight and capital-letter prescription was achieved in 31, 5 and 40% of charts, respectively. Forty-nine per cent of discontinued prescriptions were properly deleted and signed for. In re-audit significant improvement was noted in documentation of the patient's name 100%, gender 54%, allergy status 51% and use of generic drug name 71%. Similarly, in the University Teaching Hospital, 82, 63 and 65% compliance was achieved in documentation of age, generic drug name prescription and capital-letter prescription, respectively. Prescription practice was reassessed one year later after recommendations and changes in the prescription practice, leading to significant improvement in documentation of unit number, generic drug name prescription, insulin prescription and documentation of the patient's ward.

Conclusion: Prescription error remains an important, modifiable form of medical error, which may be rectified by introducing multidisciplinary assessment of practice, nationwide standardised prescription charts and revision of current prescribing clinical training.

Keywords: Prescription error; patient safety; prescribing; prescribing charts.