Scholarlink

Introduction <p>Over 1 billion prescription items are dispensed in primary care in England every year. With such volumes, general practitioners (GPs) need robust systems to manage the prescribing of repeat prescriptions to safeguard patients.</p> Objectives <p>This retrospective case series reviews coroners’ prevention of future deaths (PFDs) reports to identify where repeat prescribing processes contributed to medicine-related deaths.</p> Methods <p>PFDs published between 1 January 2019 and 31 December 2023 reporting medication-related deaths were screened. Those relating to repeat prescribing processes were included. Inductive thematic analysis was used to assess PFDs and identify where failures in repeat prescribing processes contributed to medication-related deaths. The “Matters for Concern” were reviewed and independently coded to identify key themes relating to repeat prescribing.</p> Results <p>There were 24 of 277 PFDs related to medication repeat prescribing. The majority of reported deaths were female patients (67%, <i>p</i> &lt; 0.05) with a median age of 44.5 years. Of the named medications 76% were opioid analgesics, mentioned significantly more than any other drug class (<i>p</i> &lt; 0.05). In addition, one third of the included PFDs described multiple repeat prescriptions (multi-drug toxicity) or medicines taken alongside acute prescriptions or over-the-counter medications. Overall, 54 matters of concern were raised by coroners, from which three key themes were identified: errors or discrepancies at the point of a transfer of care; the ability to obtain repeat prescriptions from multiple medication sources; and the absence of robust medication review, with the absence of review being the most commonly linked to patient deaths.</p> Conclusions <p>Medicines prescribed on repeat prescriptions can cause harm to patients and have contributed to medicine-related deaths. Failure to review medicines in primary care is a key factor in this. Inherently higher-risk medicines, such as opioid analgesics, were most commonly described and should be prioritised for review.</p>

错误：搜索内容不能为空，请输入英文关键词
错误：关键词超出字数限制，请精简
高级检索

How has the repeat prescribing process contributed to or caused patient deaths in England? A systematic, collective case series of prevention of future deaths reports 2019–2023

  • 期刊论文

  • 发表日期：

    2025年4月21日

查看全文
  • Clare Thomson,
  • Lauren Ross,
  • James Davies

摘要

Introduction

Over 1 billion prescription items are dispensed in primary care in England every year. With such volumes, general practitioners (GPs) need robust systems to manage the prescribing of repeat prescriptions to safeguard patients.

Objectives

This retrospective case series reviews coroners’ prevention of future deaths (PFDs) reports to identify where repeat prescribing processes contributed to medicine-related deaths.

Methods

PFDs published between 1 January 2019 and 31 December 2023 reporting medication-related deaths were screened. Those relating to repeat prescribing processes were included. Inductive thematic analysis was used to assess PFDs and identify where failures in repeat prescribing processes contributed to medication-related deaths. The “Matters for Concern” were reviewed and independently coded to identify key themes relating to repeat prescribing.

Results

There were 24 of 277 PFDs related to medication repeat prescribing. The majority of reported deaths were female patients (67%, p < 0.05) with a median age of 44.5 years. Of the named medications 76% were opioid analgesics, mentioned significantly more than any other drug class (p < 0.05). In addition, one third of the included PFDs described multiple repeat prescriptions (multi-drug toxicity) or medicines taken alongside acute prescriptions or over-the-counter medications. Overall, 54 matters of concern were raised by coroners, from which three key themes were identified: errors or discrepancies at the point of a transfer of care; the ability to obtain repeat prescriptions from multiple medication sources; and the absence of robust medication review, with the absence of review being the most commonly linked to patient deaths.

Conclusions

Medicines prescribed on repeat prescriptions can cause harm to patients and have contributed to medicine-related deaths. Failure to review medicines in primary care is a key factor in this. Inherently higher-risk medicines, such as opioid analgesics, were most commonly described and should be prioritised for review.