Prescribing error reporting in primary care: a narrative synthesis systematic review

Abstract

Prescribing errors can cause avoidable harm to patients. Most prescriptions originate in primary care, where medications tend to be self-administered and errors have the most potential to cause harm. Reporting prescribing errors can identify trends and reduce the risk of the reoccurrence of incidents; however, under-reporting is common. The organisation of care and the movement of prescriptions from general practice to community pharmacy may create difficulties for professionals to effectively report errors. This review aims specifically to identify primary research studies that examine barriers and facilitators to prescription error reporting across primary care. A systematic research of the literature was completed in July 2019. Four databases (PubMed/Medline, Cochrane, CINAHL and Web of Science) were searched for relevant studies. No date or language limits were applied. Eligible studies were critically appraised using the Mixed Methods Appraisal Tool, and data were descriptively and narratively synthesised. Ten articles were included in the final analysis. Seven studies considered prescription errors and error reporting within general practice and three within a community pharmacy setting. Findings from the included studies are presented across five themes, including definition of an error, prescribing error reporting culture, reporting processes, communication and capacity. Healthcare professionals appreciate the value of prescription error reporting, but there are key barriers to implementation, including time, fear of reprisal and organisation separation within primary care.

Keywords: general practice; incident reporting; pharmacists; primary care.

Figure 1

PRISMA flow diagram illustrating the study screening process. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyse.