Mistakes that I have made

The incident that I will reflect on involved a prescribing error in a 20 year old male psychiatric in- patient. He was being treated for a respiratory tract infection by me at a mental health hospital general clinic. The patient had a history of sleep and wake apnoea, severe obesity and schizophrenia (for which he was currently taking clozapine).

I had initially prescribed amoxicillin for his infection but this had been ineffective. When I saw him a week later, he was still not better and I decided to prescribe erythromycin as a second line treatment (erythromycin and clozapine in fact dangerously interact to increase the risk of seizures). My mistake had been noticed by an auxiliary nurse also present at the clinic, but she had not raised this concern at the time (after all, I am a Professor and I must have known what I was doing!). Only two days later when my colleague was reviewing the patient did the nurse reluctantly point out the error. Interestingly, even the hospital pharmacist who was dispensing the medication failed to pick up the error.

What was done following the incident?
My colleague immediately consulted the pharmacy for the most appropriate medication and cancelled the erythromycin from the prescription chart. Additionally, long term measures were undertaken to prevent future similar near misses and enhance the level of patient safety within the organisation; the nurse was reassured that she should question the actions of others even if she deem them to occupy a higher status. I was contacted and made aware of the error. This served a greater purpose in attempting to remove barriers that medical staff face in questioning the actions of other team members – I welcomed the feedback and agreed that I would speak to the nurse and give her positive feedback.

Why did this error occur?

The observing nurse displayed a delayed reaction to this prescribing error. In the first instance I can only assume that she either doubted her own knowledge of prescribing with clozapine or was afraid that voicing her concern to a more senior member of staff would be deemed inappropriate. Only after two days had elapsed did she mention the error to another GP, in which time the patient could have come to harm. However, once she had gained this support she took steps to increasing the awareness of safe prescribing with clozapine by displaying several warning notices.

Such errors can be usefully subdivided into having individual, environmental and cultural origins. Each of these areas can explain the error I have described above.

Individually based errors could relate to either the GP or the patient. The GP may have suffered a lapse in attention, failed to recognise the need to double check and communicate with colleagues, may have been overburdened with other work or may have lacked knowledge specifically about drug interactions with clozapine. That the patient had been resistant to another antibiotic also facilitated the development of this error. Environmentally based errors are also relevant as the GP was working outside of their normal surroundings and was using a different computer system. This may have served to distract the GP and also remove some of the safety mechanisms that usually prevent incorrect prescribing in primary care. Cultural issues may relate to the reluctance the nurse demonstrated in highlighting this error, perhaps, deeming it was not her place or responsibility to interject as a result of a hierarchical mentality.

This particular case has raised the issue of safety and error within general practice. It is quite possible that a large number of errors occur in primary care where the GP seems to work in isolation and there is less opportunity for shared decision making compared with secondary care. In fact in primary care errors may occur in up to 11% of prescriptions1 and it has been reported that very rarely do prescribers in primary care discuss their choices with colleagues2.

1 – Sanders J, Esmail A. The frequency and nature of medical error in primary care:  understanding the diversity across studies. Family Practice 2003; 20:231–6.
2 – Barber N, Rawlins M, Dean Franklin B. Reducing prescribing error: competence, control,
and culture. Quality and Safety in Health Care 2003; 12: i29-i32.

So the question for you is:

Who was at fault in relation to this incident?

What are the key lessons that can be learnt from this incident? (I’ll post some conclusions when some of you have had a chance to comment).

About Aneez Esmail

I am a Professor of General Practice at the University of Manchester and was an Associate Vice-President responsible for Social Responsibility from 2005-2013. I no longer work in University management. I am a practising general practitioner working in an inner city practice, and a teacher of both undergraduate and postgraduate students. I am also a Health Services Researcher and my research interests include patient safety in primary care, public health, racism in medicine and medical education. I am an active trade unionist.
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