Saturday, 7 March 2015

The Anatomy Of A Drug Error

I made a serious drug error last year. There, I said it - confession is good for the soul. Fortunately, no one was harmed but this was the first time in 23 years as a GP that I got it that badly wrong. The story is worth telling in detail as it contains important lessons for me, my practice and the wider NHS.
In a nutshell I prescribed an antibiotic (No, that wasn't the sin – there was a genuine indication!) to a frail patient in a care home whose records unambiguously contained a correctly coded allergy to that drug. The drug was prescribed, dispensed and the full course given before the error came to light. Had the patient had a significant reaction, in his/her frail state, it could easily have caused death or hospital admission.

All doctors have a mental script they rehearse when prescribing to stop this from occurring. My checkpoints for a home visit are as follows:
1) Check the patient print-out I carry where allergies are recorded on the front page
2) Ask myself, ‘Are there any other reasons, drug interactions or co-morbidities, which would contraindicate this drug?’
3) Ask the patient, ‘Are you allergic to anything?’
4) Ask the carer or relative, ‘Are they allergic to anything?’
5) On writing the visit up back at the practice, prescribe the drug on the clinical system, without printing the already handwritten prescription, as this will alert me automatically to drug errors as part of the process
6) Trust the dispensing chemist, who often has drug reactions recorded on their system, to alert me if they are aware of a problem
7) Trust the care home administering the drug will check the drug against their records and alert me if there is a problem
This has served me well for 23 years and only once before have I got to stage 5 and had to back-peddle to prevent a drug being given wrongly.

So, to the anatomy...
In August 2013, as a result of growing pressure from an increasing list in too small a building, we made an application to close our list to new registrations. In making the application one of the reasons I gave to NHSE was 
‘Increased stress on doctors raising the risk of adverse patient events’
And I concluded the application with 
‘We believe that, without a change, continuing to increase the pressure on our building by increasing our list size and continuing to the increase the pressure on individual staff because of our recruitment difficulties will necessarily result in patient harm at some future point. We are obliged to avoid this and raise the issue with the LAT and CCG. We believe our proposal is reasonable and timely.’
I quoted the relevant GMC guidance, for good measure.

It took NHSE four months (much longer than the contracted time for response) to reject our request concluding that,
‘there was adequate GP to patient ratio provision available at the practice to manage the current demand’
helpfully adding, despite our pointing out how over-stretched we were, that
‘The practice could also consider exploring seven day working as a way of managing the current demand’
We were obliged to struggle on. On 8/3/14, after a particularly bad day on call, I emailed my partners, describing my day, flagging it as a significant event for my appraisal discussion in July and suggesting that we apply for a list closure again, concluding:-
‘I don't think I did any harm y'day but the safety margins are becoming uncomfortably narrow which might be tolerable for old hands but carries a bigger risk for GPRs and less experience salarieds’
There was a general reluctance to re-apply because it was felt there would be little point, given such a negative response first time around. Nevertheless we started re-drafting an application.

In August 2014 I experienced one of the busiest days I have known in general practice. I worked from 7:45am, foot continuously on the accelerator, until after 6:30pm with no break for coffee or lunch or tea. I probably managed to pass urine once. For the first time in 22 years I was unable to complete the work I needed to do that day before being late for our Partnership meeting that evening. It was a 13.5 hour day and I cycled home exhausted. I slept fitfully and woke early, my mind racing with the events of the previous day and thoughts for the coming one, as I was to lead a meeting that afternoon to discuss federation plans with several local practices.

The fateful visit occurred later the same day, at the end of another full-on morning with no break and no lunch, with only a few minutes to get back to the surgery to lead the meeting. The patient, who I knew well, was acutely ill and needed a prescription. In my rush at checkpoint 1), I missed the drug allergy on my patient printout. I can’t remember whether I checked and just missed it or whether I just didn't check. I thought I knew the patient so skipped through checkpoint 2). The patient has dementia so no point in checkpoint 3).  I wasn’t the only person having a busy day, the carer got called away to someone else mid-consultation and so checkpoint 4) was omitted too. For some reason checkpoints 6) and 7) also failed to kick in.
I rushed back to people waiting for me and the meeting went well. Then with my mind buzzing I set about catching up with all the tasks and letters and path results that had come in that morning and afternoon and the work I had been unable to complete the previous day. I wrote up the visit and went through checkpoint 5). The computer warned me about the drug interaction but I flicked through ignoring it along with all the other non-clinically relevant warnings that come up.

A week later I was reviewing the patient’s notes for some reason and to my horror realised what had happened. I printed out the visit slip – yes the allergy was there. I tried re-issuing the drug – yes the computer did warn me. The really scary thing is that despite being a conscientious GP for 22 years, despite predicting that something like this would happen (though not to me!) and despite teaching safe prescribing habits to GP registrars for 15 years, I did not realise what was happening at the time. I was just overloaded and hitting me so I'm more careful in future isn't necessarily going to help.
We reviewed the event as a practice and we have made the visit printout even clearer and have heightened awareness but if I have another 48 hours like that I don’t think I can guarantee it won’t happen again. The only way I can avoid it is by being able to control my workload to within what I know after 22 years’ experience is safe. I had already asked for that and was refused, against my better judgement.

This all occurred a week after we had again applied for a list closure at the end of July 2014, with a pretty much identical document. We did not hold out much hope as if NHSE were consistent they would have to respond in the same way as the first time.

This time they granted our request!

I was itching to see how they would explain this volte face in the formal response. The application was identical, their response the opposite. In the event whether to hide their total inconsistency or because organisational dementia prevented its recognition, the letter merely detailed the rules and our duties concerning list closure, without any explanation of the decision.
I have no confidence in our area team. They failed to listen to my concerns first time round which was at least partly responsible for me nearly killing someone and then behaved wholly inconsistently without explanation.
Since the list closure things have been a bit better and I have no further incidents to report. But in four weeks we have to open the list again and nothing fundamental has changed. We've looked at hot-desking and made significant changes to the appointment system and phone system which will help.

Much is made of learning from the airline industry in making the NHS safer. However, NHSE, DoH and the government are not credible in this matter. The current contractual arrangements mean that there is no point beyond which a GP cannot be pushed and NHSE is quite intent to keep on pushing. This is in stark contrast to flight crew safety rules which 
‘recognize the universality of factors that lead to fatigue in most individuals and regulates these factors to ensure that flight crew members in passenger operations do not accumulate dangerous amounts of fatigue.  Fatigue threatens aviation safety because it increases the risk of pilot error...’
If only the GMS/PMS contract was as sensible.

So what is the solution to the current situation where resignation from one’s livelihood is the only reliable way to escape an intolerable safety risk? Well one thing that would help is giving GPs absolute discretion about list closure. We could have avoided the above near miss, which convinced me that Area Teams are not competent to make such decisions as they are susceptible to political pressure. It is absurd that GPs are trusted to decide on the patient with chest pain in front of them and on commissioning for populations but are denied the ability to decide on a safe workload in their own practices. The requirement to go cap in hand to Area Teams to get a list closure has contributed to the serial de-funding of primary care by allowing them to pretend there is adequate GP coverage. Politically, of course, it would cause major embarrassment as practices closed lists up and down the country but this is a crucial safety governor and would oblige proper resourcing and commissioning of primary care to save political face, which is the right way round.

And if no solution is forthcoming, General Practice will have crossed, by NHSE’s action, from ‘if’ serious patient harm occurs to ‘when’ but it will be the GP who is hung out to dry. I find myself asking a question I never dreamt I’d ask, ‘Is it ethical to be a GP?’ Should I continue to work within this system, knowing there is a real chance of inadvertently harming a patient, when it deliberately and incompetently denies me the means to minimise that risk?

So how long do I continue to push my luck? If I do err again and someone is harmed whether I appear before a coroner’s or civil or a criminal court, or the GMC or the Health Ombudsman or the CCG Performance Committee or CQC or the latest ‘Safety’ Agency, I’ll produce this blog as evidence for the defence, M’lud.

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