Prescribing error reporting in primary care: a narrative synthesis systematic reviewPrescribing error reporting in primary care: a narrative synthesis systematic review

Abstract

Prescribing errors can cause avoidable harm to patients. Most prescriptions originate in primary care, where medications tend to be self-administered and errors have the most potential to cause harm. Reporting prescribing errors can identify trends and reduce the risk of the reoccurrence of incidents; however, under-reporting is common. The organisation of care and the movement of prescriptions from general practice to community pharmacy may create difficulties for professionals to effectively report errors.This review aims specifically to identify primary research studies that examine barriers and facilitators to prescription error reporting across primary care. A systematic research of the literature was completed in July 2019. Four databases (PubMed/Medline, Cochrane, CINAHL and Web of Science) were searched for relevant studies. No date or language limits were applied. Eligible studies were critically appraised using the Mixed Methods Appraisal Tool, and data were descriptively and narratively synthesised.Ten articles were included in the final analysis. Seven studies considered prescription errors and error reporting within general practice and three within a community pharmacy setting. Findings from the included studies are presented across five themes, including definition of an error, prescribing error reporting culture, reporting processes, communication and capacity.Healthcare professionals appreciate the value of prescription error reporting, but there are key barriers to implementation, including time, fear of reprisal and organisation separation within primary care.

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: The QUMwatch study

“…102 Nonetheless, system factors were reported or deduced from the narratives and were linked in the majority of incidents to inadequate procedures, poor risk management activities or safety culture. Consistent with other studies, 49,51,100,103 a major organisational factor affecting nearly half of all incidents in our study was communication, especially the management of prescription information between the prescriber and the pharmacy and between providers and the patient.…”

“…95 The most frequently reported healthcare provider factors that precipitated MIs were mental in nature. Most of the available literature on CFs to date has focussed on the prescribing stage, [96][97][98][99][100] wherein multiple CFs for each incident are usually identified including cognitive error. Incidents in community pharmacy are also the product of cognitive errors with one study reporting approximately 80% of dispensing errors are associated with cognitive processes.…”

Exploration of prescribing error reporting across primary care: a qualitative study

“… 17 Furthermore, around 5% of prescriptions in primary care are estimated to include suboptimal or unsafe prescribing, although this figure varies widely and definitions are used inconsistently throughout the literature. 18 19 …”

“…It has been estimated that up to 70% of medication errors within primary care are prescribing errors,16 and an audit in general practices in England identified an error rate of 12.5% in medicines prescribing 17. Furthermore, around 5% of prescriptions in primary care are estimated to include suboptimal or unsafe prescribing, although this figure varies widely and definitions are used inconsistently throughout the literature 18 19…”

“…Decisions and behaviours around medication error reporting can be complex,18 and a number of barriers to error reporting have been identified across other settings and error types. These include: awareness and functionality of incident reporting systems;23 24 the need to clarify reporting criteria;25 and sociocultural, organisational and political processes and agendas relating to professional practice, regulation, social inequalities, control and power 26–28.…”