Medical Matters Tom O'DowdDoctors' handwriting is generally hard to read even by doctors themselves. This has led to massive computerisation with many general practices in Ireland now recording all consultations on computer. When we became computerised in my practice, complete with printed prescriptions, one of my colleagues said "the chemist will now be able to read everything".
Scotland is a leader in GP computing with a sophisticated system for recording and networking anonymised clinical information. Electronic formularies are now available with regularly updated lists of drugs with advice on indications and interactions. Computerised prescribing packages usually have a warning system built in to alert the doctor to dangerous interactions. It also enables the doctor to know if the patient is adhering to the prescription. It always surprises doctors to know that nearly half our patients do not take their medication as prescribed.
GP computing is evolving however. Zyban is an oral medication that some patients find kills the desire for nicotine and helps the patient stop smoking. Recently two practices in Glasgow responded to smokers' requests for help to quit the habit with prescriptions for Zyban.
When the doctors typed in Zyban, their new e-formulary developed a mind of its own and selected Sildenafil. The trade name for this drug is Viagra which is prescribed for erectile dysfunction.
The error went unnoticed, the prescriptions were signed and eager smokers presented their prescriptions to the pharmacy for Viagra thinking it was just the job for killing the desire to smoke. The official line from Greater Glasgow and Clyde NHS Trust is that no one left the pharmacy with the wrong drug as the ever vigilant pharmacist spotted the error. However, it is likely that some smokers were happy with the error and that it was only when female smokers presented with prescriptions for Viagra that the glitch was traced.
Safety in drug design and development is of prime concern to the manufacturers. Complex trials of new drugs take place in animals and human volunteers before being used on carefully selected patients. The results have to be vetted by regulatory authorities such as the National Drugs Advisory Board in Ireland before being released for general prescribing.
A recent study of errors in general practice in the northeast of England involving 10 general practices showed that 940 errors occurred in the two weeks of the study period. This worked out as 76 mistakes per 1,000 appointments. The mistake categories were communication, appointments, equipment, clinical care and, finally, prescriptions. Over 40 per cent were related to prescriptions although just 22 out of the 940 errors were medication mistakes. This is usually taken to mean errors in dosage, frequency and even the wrong drug.
This sounds like too many and yet it is surprisingly low, considering that a GP may write or print 40-50 prescriptions a day.
There are an additional set of prescriptions that causes much concern to GPs. It is the repeat prescription where patients with a chronic illness ask the receptionist for another month's supply without seeing the doctor. Most of us sign these at the end of a busy morning hoping the patient, receptionist and computer have all got it right. However, for it to be a safe task it requires a level of vigilance, training and knowledge that is often not appreciated. It is one of the most dangerous tasks in practice and yet if it did not occur, general practice as we know it would disappear or become unaffordable. Indeed, some GPs charge significantly less for a repeat prescription thereby creating an incentive for it to continue.
Many prescriptions are short term and for medications that are tried and trusted or for creams and ointments that act on the skin. It is for this category that some think would be a useful place to start nurse prescribing. However, the more you think about prescribing the more cautious you become.
And finally, if the smoker in your life comes home with a spring in his step check his pills. Especially the blue ones.
Dr Tom O'Dowd is a practising GP and professor of general practice at Trinity College Dublin.