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Medicines safety

What is the extent of prescribing errors in discharge letters?

The work described here was presented at the Pharmacy Together 2019 conference.

Polypharmacy is common in patients with renal disease. This patient cohort is at greater risk of prescribing errors and consequent potential harm from medicines. The provision of poor-quality discharge information about medicines can lead to medication errors, associated adverse events and hospital readmissions. 

Recent incident reports and anecdotal evidence highlighted a series of medicine errors on discharge letters from the renal in-patient wards at a tertiary renal centre. Our objective was to evaluate the prevalence, nature and severity of prescribing errors on renal discharge letters.

All discharge letters generated using the PROTON™ computer system and screened by pharmacists from renal wards at an NHS Trust were collected over a three-week period in February 2019. Prescribing errors identified by pharmacists were retrospectively recorded and categorised by type and severity. Errors were reviewed by two senior renal pharmacists with the severity of errors agreed by consensus. 

A total of 83 discharge letters were evaluated, containing 1128 prescribed items. One or more prescribing errors were identified in 81 percent of discharge letters. All discharge letters were written by junior doctors. FY1 doctors made more prescribing errors than FY2 doctors, and they made 68 percent of serious errors and 60 percent of significant errors identified. 

A significant proportion of discharge letters from renal wards contain prescribing errors, many being serious or significant in nature

This suggests that experience gained through foundation training enabled junior doctors to be safer and more accurate prescribers. System-related factors were common with around a third of errors related to functionality limitations of the PROTON™ computer system, including unavailability of some medicines on the system and restrictions in dose specifications.

The most common types of errors were medicines omitted, medicines prescribed when no longer required, and wrong frequency. Thirteen percent of errors were serious, just over half were significant and around a third were minor. A large proportion of serious errors involved high-risk medicines including insulin (18 percent), antimicrobials (14 percent), and anticoagulants (14 percent). 

This study is limited as no discharge letters written by more senior prescribers were encountered during the study period. This study also only included prescribing errors identified on letters reviewed by pharmacists. It is conceivable that discharge letters not screened by pharmacists will include errors that may be not be detected. 

This study demonstrates that a significant proportion of discharge letters from renal wards contain prescribing errors, many being serious or significant in nature and potentially putting patients at risk of harm. Junior doctors should be targeted for education and training to improve the quality and safety of prescribing at discharge. Further work is also needed to resolve limitations within, and reduce errors induced by, the PROTON™ prescribing system. 

This work was presented as a poster at the Pharmacy Together 2019 conference, organised by UKCPA and Pharmacy Management.

Additional authors:

Maria Martinez, Ryan Hamilton and Margaret Robinson, University Hospitals of Leicester NHS Trust, Leicester

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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