The NPA has been made aware of a number of serious prescribing errors related to antibiotics. The following examples seek to highlight the importance of reporting prescribing errors, which remain generally underreported

Examples of prescribing errors

One of the most common antibiotic prescribing errors is ‘blind’ prescribing when antibiotics are prescribed without any culture or sensitivity testing. ‘Blind’ prescribing not only contributes to antibiotic resistance but can lead to further difficulties in diagnosing patients.

A number of cases have been reported to the NPA when patients with a penicillin allergy have been prescribed a penicillin- based antibiotic or cephalosporin – this may be due to the prescriber’s lack of familiarity with the class of penicillin antibiotics, or potentially insufficient knowledge about cross sensitivity with cephalosporins and other beta-lactam antibiotics. In many cases, the prescribing incident was identified during the dispensing process when the patient medication record (PMR) highlighted the allergy, reiterating the importance to note any allergies on the PMR and Summary Care Records (SCR).

Other serious antibiotic prescribing errors include tetracyclines prescribed in pregnancy and during breastfeeding, potentially causing dental discolouration in the child, and trimethoprim used during the first trimester of pregnancy in women at risk of folic acid deficiency, without folate supplementation, increasing the risk of congenital malformations due to the folate antagonist effects of trimethoprim.

Inappropriate dual prescribing is another antimicrobial prescribing error frequently seen in primary care. For example, patients prescribed co-amoxiclav and amoxicillin together, two penicillin-based antibiotics, increasing the risk of adverse effects for the patient.

How to remain vigilant to antibiotic prescribing errors and manage them:

1. Clinically check the prescription using the following suggested checklist:

• Has a bacterial culture and sensitivity test been completed?
• Is the antibiotic appropriate for the infection/causative bacteria?
• Is the antibiotic prescribed following any local or national prescribing guidelines?
• Is the antibiotic suitable for the individual? Consider a patient’s age, weight, allergies, renal and hepatic function, pregnancy, breastfeeding, co morbidities and concomitant medication – confirm such details with the prescriber, PMR or SCR, where available
• Is the dose appropriate for the indicated infection and antibiotic prescribed?
• Is the duration of treatment correct for the indicated infection and antibiotic prescribed? All prescriptions should specify the duration of treatment, if not confirm with the prescriber or check the patient SCR
  Is the route of administration suitable for the indication and individual? For example, if the patient is vomiting frequently, will an oral antibiotic be sufficiently absorbed?

2. Use appropriate reference sources to obtain the relevant clinical information. These include the British National Formulary (BNF), BNF for Children, National Institute for Health and Care Excellence (NICE) range of evidence-based antimicrobial prescribing guidelines to provide specific clinical advice and prevent the growing threat of antibiotic resistance, local prescribing guidelines, the Summary of Product Characteristics (SPC) for the antibiotic, and the NPA Pharmacy team.

3. Contact the prescriber to clarify their intentions and discuss the prescribing error; make suitable records/notes on the PMR and arrange for a new prescription to be issued if required and as appropriate.

4. Counsel the patient on appropriate use of the prescribed antibiotic.

5. Report the prescribing error(s) to improve reporting and learning from prescribing errors/incidents via the NPA Patient
Safety Incident report form (England and Scotland);National Reporting and Learning System (NRLS) (Wales); or Health and Social Care (HSC) Board anonymous reporting form (Northern Ireland).

For further information call 01727 891800 or email pharmacyservices@npa.co.uk