incorrect prescription (over dosage) - follow up?

I think that was my thread. At the time I was assured that there would be an official ‘investigation’ but without chasing and making a complaint I would never know the outcome.

I was too tied up with other stresses in my life so left it at that.

It could have been this one.
https://singletrackmag.com/forum/topic/being-given-the-wrong-injection/

reading the detailed sheet in the box....... it became apparent that he’d been prescribed an adult dose

You are supposed to read the stuff that comes with it warning you that you might die, that is why it is almost impossible to get the pills out without first removing the paperwork.

Personally I would let it go, the protocol worked, you read the bumf and your child didn't take the wrong dosage. And tbh I would be surprised if it would have caused him a great deal of harm if he had taken double the dose of antibiotic, although obviously I don't know.

I've been through the complaints process regarding a number of GPs. You're welcome to send me a PM.

So the error was in the prescription from the GP, not the quantity dispensed by the pharmacist?

I would write to the practice manager at the surgery, drawing their attention to the issue, and asking them to look into it. You can do no more, and if there is a glitch in their prescribing software that is throwing up adult doses for child patients they should be very grateful for you flagging up the issue, and you will possibly help prevent avoidable harm to someone else.

They are lucky that you are vigilant and had access to a mate with the expertise to confirm it.

Personally I would let it go, the protocol worked, you read the bumf and your child didn’t take the wrong dosage.

Relying the patient's father reading a scrap of paper as the last line of defence against potential harm from antibiotic overdose doesn't seem like the protocol working well to me. Flucloxacillin is a not a mild antibiotic, and while it was unlikely to cause serious damage, there would a increased chance of side-effects such as diarrhoea/vomiting.

Believe it or not, forward-thinking medical professionals value being told about mistakes, because it means they can look at the 'protocol' and, if there is an problem, human or otherwise, they can stop something far worse happening to someone else as a consequence.

it was @zippykona thread that I was thinking about, but it seems the circumstances there are significantly different.

So the error was in the prescription from the GP, not the quantity dispensed by the pharmacist?

correct, I checked these (and also checked the dob on the label in case that was the reason behind the mis-diagnosis) and the prescription was followed correctly (whether the pharmasist should have picked it up is a question, but I think its less likely)

You are supposed to read the stuff that comes with it warning you that you might die, that is why it is almost impossible to get the pills out without first removing the paperwork.

I genuinely did not know this is the case. I've never been told to do it, and always just trusted the doctor before. It was only because these pills were massive that we thought to check.

Flucloxacillin is a not a mild antibiotic, and while it was unlikely to cause serious damage, there would a increased chance of side-effects such as diarrhoea/vomiting.

my concern is not really the danger to my child (as he luckily didn't take any) - more that if process didn't stop an adult dose being given to him, could it also lead to some newborn being given an adults dose of something more potent (won't someone think of the children, etc).

You’re welcome to send me a PM.

appreciate the offer. I don't feel like I need support, just whether a letter in was overkill, but it appears (from initial feedback) that it isn't.

There's about 45,000 recorded prescription errors per year in the UK, leading to about 30 deaths and 6,000 people harmed, so by all means report it but don't expect much to change....

https://www.theguardian.com/society/2022/sep/26/almost-6000-people-harmed-by-prescription-errors-in-nhs-last-year#:~:text=The%20vast%20majority%20of%20prescription,2020%20to%2043%2C452%20in%202021.

Yo're correct - the kid dose of flucloxacillin at that age is 250mg four times a day...
However, kids CAN receive higher doses in severe illness (not this case, however!)

What i suspect happened is that in the prescribing 'dropdown box' the GP accidentally clicked 500mg, rather than 250mg liquid (could have rolled the mouse wheel etc..). of course they shouldhave checked, or the chemist shouldn't have issued, but it's good you saw it.. This is the classic 'swiss cheese error' - all 'holes' line up to allow an error to take place.

There's no automated system in place to prevent this happening - it would be great if there was (i.e age awareness of teh IT system) but there isn't, and an individual practice can't amend or add this function.

By all means, raise it as a "please be aware next time", but TBH I think you're being fair NOT raising an official complaint. Save that for if something really does go wrong or staff are rude/significant errors.

DrP

^^I agree

You have raised the issue so let them look at it. Errors do happen as GPs/pharmacists etc are human. I know when errors do happen they will feel bad enough and be looking at what went wrong and how to avoid it in the future. Unless you have an other concern re the GP I would let it lie and keep your powder dry.

I genuinely did not know this is the case. I’ve never been told to do it, and always just trusted the doctor before. It was only because these pills were massive that we thought to check.

Well yeah it's good to trust your GP and pharmacist but they really can't go through the whole medication in detail, the patient information that comes with it is useful for that.

Obviously a lot needs to be ignored such as the worse case scenario which points out that you might die if you have a allergic reaction, but there is plenty of useful stuff such as when to take, spacing, possible side effects such as drowsiness, etc.

I always read the bumf the first time I take a medicine. A while back after reading information I realised that something I had been given wasn't appropriate for me because another GP had given me something which ideally couldn't be mixed, can't remember what. The patient also has some responsibilities.

There’s no automated system in place to prevent this happening

It's surprising really. Since the age of the patient is always on the prescription it is surprising that if the dose doesn't match the age it doesn't flag up at least a warning when the prescription is being printed, or the pharmacist tries to dispense it.

There’s no automated system in place to prevent this happening

Wow, really? When I worked in the GP trade press back in the 90s, they were just bringing in electronic prescribing/clinical coding systems for GPs to work alongside electronic patient records which would bring up BNF information, offer correct doses etc. I just assumed there would now be an 'are you sure?' box to click for any potential mismatch between dose and patient.

If that happened in our practice I’d expect the most to happen would be for there to be a “significant event analysis” discussion at one of our monthly meetings and some lessons learnt and minuted. Maybe just for the individual maybe for the team. It would be a short one though. “I made an error, it’s no one else’s fault and there’s not a lot that we can change in our systems to guarantee it will never happen again. I’ll be more careful in future”

If we are named in formal complaints we are supposed to discuss this at annual appraisals. We need to do these every year and then once every 5 years our licence to practice can be revoked if there are massive problems. This sort of thing wouldn’t register though.

I’m quite surprised it got past the pharmacist who would normally be contacting the prescriber to check that they really meant to write what they did.

We have had to prescribe tablet antibiotics to kids (guidance says from age 4-5 is possible) recently due to the shortage of liquid antibiotics brought about by the strep A panic before Xmas. Flucloxacillin wouldn’t have been affected by that though.

At the end of the day only you know if you are happy with the information and conversation you’ve had and if not you would need to go down the formal complaint route.

If what you want is tracking of all prescribing errors and some sort of system for action against individuals at certain threshold then you’ll be disappointed, there is a lot of effort put in to reduce harm from prescribing errors but it’s aimed at prevention after looking at common themes, systems etc rather than blaming clinicians and applying sanctions to them.

A  patient reporting a script error would have triggered a significant event process in our practice, but as the docs in the thread have said it’s a way of monitoring the errors and highlighting areas for improvement rather than making sure this sort of thing will never happen in the future.

<span style="font-size: 0.8rem;">I am surprised it got past the pharmacist as well as the GP. Well done OP for checking the dose. </span>

If that happened in our practice I’d expect the most to happen would be for there to be a “significant event analysis” discussion at one of our monthly meetings and some lessons learnt and minuted.

Thanks. I think my question is, by us phoning them up and having somone re-issue a prescription will this “significant event analysis” definitely happen? Or can the doc just sweep it under their carpet? if the former is the case, I don't want to take it any further (its been tracked then) - I just want the statistical point to have been noted (even if its just amongst the 5 or so GPs who he shares a practice with)

So in the past I've dabbled in prescribing systems. I believe the bulk of the prescribing products in the UK use the same underlying drug data file. This can be implemented in lots of ways and three are lots of features that can be optionally used. A few that could flag up the issue.

1. Is that particular formulation (strength and form) licensed for children or is it even contraindicated (unlikely). The drug data file has the ability to flag that up if the system has been built to take that into account. Again however there are legitimate reasons for prescribing an unlicensed formulation or drug.

2. Dose range checking. This is effectively making sure the prescribed dose is in the expected range for the patient. Normally based off age, but can also take into account weight and body surface area. This isn't (wasn't) available for all drugs so understandably they started on the ones that have the highest risk of killing if mis-prescribed. Methotrexate being an example. I'd be surprised if an antibiotic was on that list as the side effects of over prescribing are unlikely to be significant. However there are scenarios where you can legitimately over or under dose.

You may have expected the pharmacist to flag it up as either an over dose or wrong formulation. Again having said that our youngest used to hate liquid antibiotics, so had tablets from a young age.

As you can see I'm the guy everyone wants to talk to at parties 😂

It would be good practice for this to be raised in the (er) practice somehow.,..but of course, they MAY just ignore it. But TBH, if it's fed back to the GP I suspect they will be more 'alert' next time they deal with kids.

I'm forever checking kiddie doses as it frequently changed (Docs..remember a few years ago amoxil and fluclox just doubled in strength for kids overnight!)

RE the automated system:

It’s surprising really. Since the age of the patient is always on the prescription it is surprising that if the dose doesn’t match the age it doesn’t flag up at least a warning when the prescription is being printed, or the pharmacist tries to dispense it.

I'm not 100% truthful...there ARE pop-ups to prompt you for cheaper alternatives (tablets rather than capsules) or for local presribing guidance (i.e if i try to prescribe fancy antibiotics, I get told it'll cause other issues etc..), and the system WILL pop up certain drug or health interactions (i.e i am alerted if I'm gonnas tick an old pateint on a THIRD blood thinning tablet, for example)..but age pop-ups aren't a thing..

DrP

“I made an error, it’s no one else’s fault and there’s not a lot that we can change in our systems to guarantee it will never happen again. I’ll be more careful in future”

It may not be in your gift to change the software system, but it IS in your remit to alert the people who provide the software that there is a risk that they could mitigate.  It may not even need them to change the code, or do anything fancy - having two likely options next to each other on the list, or adding liquid / tablet to the name so it is more obvious.  If nobody tells the people speccing the IT about these issues they have no idea.  Their WILL be a way to escalate concerns upwards.  "I'll be more careful in the future" is almost never the answer for safety related problems.  I'm not criticising the Dr - i'm citicisng the whole industry of medicine and they way they approach safety.

I'd also mention to the pharmacist as having a pharmacist in the family I'm always being told they exist to fix Dr's mistakes!

Or can the doc just sweep it under their carpet?

Only way you’ll know is by asking. I had to speak to a patient about a similar but different issue recently (human/systems error, discovered, no harm done, let’s look at what happened and try and make sure it doesn’t happen again- data breach). I made sure I told them that we would have a meeting with relevant staff to see what lessons we can learn and how we might make changes if we need to, and they were happy with that. You don’t need to make it a complaint but you could ask the question- it’s completely reasonable to expect there to be some sort of reflection on this. Sounds like you’ve not had the reassurance you need.

@jeffl very interesting stuff- there’s plenty of scope for intelligent systems to aid with prescribing and lots are in use- I have a particular issue with pregabalin after an ex colleague started someone on an off licence dose and it wasn’t flagged for a long time afterwards until the patient became ill. It should be a lot harder to prescribe outside of the BNF licenced dosing.

I always read the bumf the first time I take a medicine

A slight tangent on the OP, but it is worth repeating what Ernie has said, I have had a couple of instances where I have had pretty nasty reactions to what you would imagine are fairly benign over the counter meds - voltarol in particular. I am super cautious now and always check the possible side effects and what is in them to see if the stuff I react to is in there.

I’m quite surprised it got past the pharmacist who would normally be contacting the prescriber to check that they really meant to write what they did.

Yeah - this was my first thought. Did you mention to the pharmacist that these were for your son? If memory serves, I'm usually asked "are these for you?"

Also, I'm not really clear on whether both the dosage AND the DOB on the prescription were incorrect? Or just the dosage?

Mistakes do happen, but I'd be surprised if the GP got both the dosage and the DOB wrong (in which case he's prescribed medication for completely the wrong patient, which is rather more serious). If the DOB on the prescription was correct, then the Pharmacist should really have caught the error. A child being prescribed the adult dose of a drug is pretty much exactly what that kind of standard check is there for - and if that's failed, they need to know about it.

I would write to the practice manager at the surgery, drawing their attention to the issue, and asking them to look into it.

That is exactly what I would do.

Writing a letter to the GP is good, but you're relying on them to then process it, which may not happen (purely due to time pressures rather than intent).

Instead or as well, use the formal complaints mechanism if there is one. Then it gets processed by people that are paid to do that and it becomes part of the statistics, which is quite important.

Also, I’m not really clear on whether both the dosage AND the DOB on the prescription were incorrect? Or just the dosage?

Prescriptions show a patient's actual age so presumably those fields are autofilled without input from the GP.

Thanks ernie, my point was: was the age/DoB correct or not?

If wrong, serious issue at the GP

If right, serious issue at the pharmacy

Personally I would let it go, the protocol worked, you read the bumf and your child didn’t take the wrong dosage.

I wouldn't. Basically the only way this can be fixed going forwards is to create a paper trail showing that a "near miss" occurred, and it was only your vigilance that protected your son. Other parents might not be able to read the pamphlet, or would just assume that the doctor is right ('cos doctors are always right...) and chop the tablet up or something.

We need to drop this concept that reporting mistakes and errors in healthcare is "grassing someone up". Instead the mistake needs to be tracked in an SMS and if there's a series of them, the root cause identified and a solution found. Not mentioning it because the doctor is working hard is not an excuse, especially if that's the actual reason it happened.