Section 4Treatment issues
Confusion over drug name MDU advice
A male patient had attended for a prescription of While acknowledging the GP’s concerns, the medico-legal
vitamin B12 (hydroxocobalamin). When the GP adviser was able to reassure him that providing an open
issued the prescription, he followed his normal and honest account of his mistake and an apology is not
procedure of selecting it from a drop-down list on the same as admitting liability and can help reduce the
his computer. Unfortunately, instead of selecting risk of a complaint. Such action is enshrined in law in
hydroxocobalamin he unwittingly selected the Section 2 of the Compensation Act 2006 that says ‘an
next drug on the alphabetical list. This was apology, offer of treatment or other redress, shall not of
hydroxycarbamide, a chemotherapeutic agent itself amount to an admission of negligence or breach of
used in the treatment of leukaemia. The GP issued statutory duty’. It is also part of the GMC’s Good Medical
a prescription for this instead. Practice guidance(2006, paragraph 30).
When the patient presented his prescription at the The adviser was able to assist the member in drafting a
pharmacy, the pharmacist queried it. The patient confirmed letter to the patient that explained the details and
that he was expecting a supply of B12, but rather than possible ramifications of the error in clear, non-technical
checking with the prescribing GP, the pharmacist instead language. The GP also repeated his unreserved apology
dispensed hydroxycarbamide in line with the prescription. for the mistake and explained what steps the practice
The patient took the drug for 42 days. He then returned
had taken to prevent a similar error occurring.
to see the GP complaining of swollen ankles. In addition, He explained that he had identified and recorded the
having read the drug leaflet, he was terrified he might matter as a critical incident and had arranged a
have leukaemia which the GP had not told him about. significant event audit meeting with colleagues in the
The GP was disturbed to discover the error and
practice to discuss the error.
immediately explained his mistake to the patient and At the meeting the case had been discussed and
apologised. The patient, while very relieved that he was reviewed in order that the practice could learn from the
not suffering from leukaemia, was understandably mistake and make any improvements necessary. It was
concerned about possible damage the drug had done. agreed that the case served as a warning and reminder
The GP then contacted the local haematologist to clarify
to prescribers within the practice to be extra vigilant
any possible consequences for the patient and discussed
when prescribing drugs with common stems.
the case with the regional Medicines Information Service. It was decided that the member would write to all the
Information on any aspect of drug therapy can be sought local chemists reminding them to check with the
from the Medicines Information Service and the contact prescriber if they had any doubts about a prescription.
details for local services within the region can be found
inside the front cover of the BNF.
In addition the GP offered the patient a meeting to
discuss the error and the lessons learnt.
When the member contacted the advice line he was very
anxious about what had happened. He asked how much
The member was also advised to inform the National
information he should share with the patient regarding
Patient Safety Agency of the error and to raise the issue
what was a clear-cut error on his part. He was concerned
with the dispensing pharmacist as analysis of the incident
that excessive openness would alarm the patient and
had highlighted systems failures involving the whole
could be used against him in any proceedings that might
process of drug delivery, from prescribing to dispensing.
follow. Additionally, the member was advised to ensure that all
actions relating to the issue were documented and
recorded in the patient’s records.
Following the incident, the patient was monitored on a
regular basis with routine blood tests. He displayed a
transient raised result in liver function tests that quickly
normalised, but apart from that suffered no adverse
effects.
In due course the patient left the practice area and made
a point of writing to thank the GP for the care he had
received.
“…an apology, offer of treatment or other redress, shall not of itself
amount to an admission of negligence or breach of statutory duty…”
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