Patient safety deficiencies

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Thanks to new drugs and indications, the possibilities of successfully treating patients with drugs are constantly increasing. More elderly people, a higher level of ambition and increased specialization have also led to more contacts with care for many patients. A high priority project in the National Medicines Strategy is the introduction of a comprehensive outpatient drug list (based on the national prescription database).

For this to be of benefit, and not with new risks to patient safety, clinicians need to agree on working methods, roles and responsibilities for a patient’s drug treatment.

The purpose of this article is to describe a model for how roles and responsibility for a drug list can be distributed amongst different physicians. This applies irrespective of whether IT support, for example in the form of electronic patient records, is available or not.

Patient safety deficiencies

The Pharmaceutical, IT and Medical Technology Council of the Swedish Medical Society and the pharmaceutical committees in Sweden contributed to the development of the model through discussions. Based on this model we have developed, the Swedish Medical Association and the Swedish Drug Committee Network have now identified eight items that describe how best to deal with prescribing responsibility and general patient care in different situations.

Patient safety deficiencies

In outpatient care, the patient is expected to self-medicate, possibly with the support of relatives, friends or care staff. In order for this to be possible, the patient must know, inter alia, what drugs to take from what packages, how, when and why these drugs are taken, for what disease they are intended and what treatment goals are. In addition, the patient needs to know when and how to check their medications and possibly renew their prescriptions, and which doctor (s) are responsible for this.

In today’s practice, the implementation of home treatment is hampered by the fact that generic replacement leads to the names and appearance of packages and tablets with the same substance changing over time.

In recent years, work to improve patient safety has increasingly focused on the mistakes that arise when switching care, when new care staff takes responsibility for the patient. One of the main problems with these transitions is drug information. In 2009, the Swedish Drug Committee Network developed a document describing the responsibility for the general list of drugs in the electronic patient record. This provided the basis for local guidelines, but compliance with them is not documented.

Unfortunately, the list of medications in the patient record is not always updated so that all current medications are included in the current dose and all outdated medications are disclosed. Lists available in pharmacies in the form of a list of drugs (drugs issued within the last 15 months) and a prescription register / prescription warehouse (digitally stored, current prescriptions) do not have conditions to describe what drugs the patient expects to take on a given day.

Dose may change, medications may be exposed or not known to a physician when deciding on a patient’s overall treatment, there may be several prescriptions for the same drug from different physicians, and outdated prescriptions may not be destroyed.

Even with the patient’s consent, physicians cannot directly access information about all digitally stored patient prescriptions in the prescription registry. Therefore, it is not possible for a doctor, for example, to ensure that all prescriptions that are not suitable for the patient are canceled. This deficiency must be rectified by a change of law, but such a change only addresses the issue of access to information, not the issues of roles and responsibilities.

Information about the patient’s own treatment with over-the-counter medications, dietary supplements and his own dose adjustments of prescribed medications is often missing from the patient’s records and is also not available from two pharmacy registries. When this information is important for the physician’s assessment, the documentation is supplemented with the patient’s information about it and the patient’s own account of the course of the prescribed treatment.

Different perceptions of responsibility

Responsibility for the treatment of addiction is generally regulated by the Healthcare Act and the Patient Safety Act.

Regulations that directly regulate the responsibility for prescribing medicines are the rules and general guidelines of the National Council of Health and Social Welfare.  However, the roles and responsibilities of the prescriber, usually the physician, are not discussed in situations with several physicians who are independent of each other.