PRESCRIBING errors constitute one of the top risk areas for general practice and account for 13 per cent of all GP claims reported to MDDUS. The harm caused by incorrectly prescribed or unmonitored medication can be serious and long lasting.
When it comes to online prescribing, the risks become even greater, especially if GPs don’t have a face-to-face consultation prior to issuing the prescription. GPs must therefore be mindful of these additional risks and, where necessary, take measures to ensure patient safety isn’t compromised.
A recent report from Care Quality Commission (CQC) inspectors found that 43 per cent of independent online primary care services in England are not providing 'safe' care. Among specific concerns, inspectors found that some online providers were not collecting patient information or sharing information with a patient’s NHS GP, who should have an accurate and up-to-date record of their previous and current treatments and health issues. They also found inappropriate prescribing of antibiotics for long-term conditions as well as prescribing high volumes of opioids issued without prior discussion with the patient’s registered GP.
Each prescriber takes responsibility for the prescriptions they issue, so doctors must be prepared to explain and justify their decisions and actions when prescribing, administering and managing medicines. When it comes to online prescribing, GPs may not have access to a patient’s relevant medical history or usual medications. They may also find it difficult to ensure their involvement in the patient’s ongoing medical care is accurately recorded in their usual medical records, significantly increasing the risk of inappropriate prescribing.
In circumstances where the GP hasn’t physically seen the patient they need to be alert to the risk of people purporting to be someone they are not. It may be appropriate to undertake additional due diligence in these instances, such as asking the patient additional questions to confirm their identity.
Although it would be prudent to record such questions in your records, it may be more helpful for practices to adopt a policy for online prescribing for practice patients which incorporates these checks and is used as standard. It is worth checking with a senior colleague or practice manager whether your practice has such a policy in place.
Many GPs implement an online prescribing system which asks a checklist of questions before a prescription can be issued. In the event you use such a system, you need to ensure it is appropriate for each medication issued and allows you to ask more questions or speak to the patient in person if required. GPs should consider if they have the same information they would want to be aware of if they were seeing that patient face-to-face.
The GMC underlines this point in its guidance Prescribing and managing medicines and devices, saying: "Before you prescribe for a patient via telephone, video-link or online, you must satisfy yourself that you can make an adequate assessment, establish a dialogue and obtain the patient’s consent".
Ultimately, the final decision to prescribe should always be a clinical assessment by the doctor rather than relying solely on an online system.
It is worth adding here that nonsurgical cosmetic medicinal products such as Botox, Dysport or Vistabel or other injectable cosmetic medicines cannot be prescribed online. The GMC requires doctors to undertake a physical examination of patients before prescribing these, adding: "You must not therefore prescribe these medicines by telephone, video-link, or online."
There is also a risk that a patient may be seeking online prescriptions from several sources. It is important all doctors prescribing online are alert to these risks, particularly if the medication requested has the potential for abuse or is associated with potentially serious side effects.
Abuse of prescribing is taken very seriously by the GMC. Your practice should have robust systems in place for the issuing and review of prescriptions, particularly for drugs which may be abused. These systems should cover all prescriptions and should include regular tailored audits.
Doctors must provide effective treatments based on the best available evidence. GMC guidance Good Medical Practice advises that doctors should: "Prescribe drugs or treatment only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs."
Finally, always communicate your decision to prescribe (or not) effectively to patients to avoid unnecessary complaints. If you do not feel you have the appropriate knowledge and experience to prescribe a particular medicine, you do not have to do so. But you should explain your reasons for declining and explain other available options, including the option to seek a second opinion. As always, these discussions and the justification for your decisions should be clearly noted in the patient record.
If you are considering undertaking work of this nature we would advise you to contact MDDUS, in order to ensure you have appropriate indemnity in place.
Dr Naeem Nazem is a medical adviser at MDDUS