NHS England recently received notification of an incident in which a medicine being prescribed for a patient by their consultant was also prescribed by their GP in error.
The patient received and took a double-dose for a period of time before falling ill and being admitted to hospital.
The patient’s consultant was prescribing clozapine and amisulpride for them, which was dispensed by a hospital pharmacy.
The amisulpride prescription was added to the patient’s record at the practice as a normal repeat medication, and a prescription was subsequently issued.
The dispensing pharmacy that supplied medication for the patient in a compliance aid (dosette box) queried this new prescription with practice staff. The non-clinical staff that took the call confirmed that it was a new medicine and was to be dispensed. The patient then took the medication in their compliance aid along with the medicines prescribed by their consultant.
It is good practice to record medicines that patients are receiving from other prescribers in the clinical system, but it must be clear that these are not to be issued by the patient’s GP unless there are exceptional circumstances.
This ensures that primary care staff have an up-to-date record of all of the medicines a patient is taking, and that this is shared with others via the Summary Care Record or when sharing a summary on request.
As an example in EMIS they are listed in the current medication screen, but in a separate ‘hospital only’ section from which they cannot easily be issued in error.
A range of guides on how to perform this task are published online by colleagues in Manchester:
Management of Red Listed Drugs in Primary Care (includes TPP, INPS, EMIS, and Microtest)
[This article appeared in "GP Bulletin 297" (NHS England SSW, 04 01 2019)]