Dr L was the duty doctor on call. She received a message from reception. Mrs A had been in and had asked for a repeat prescription for her warfarin tablets. She was only issued with a prescription for warfarin last week and the computer would not allow the receptionist to issue a further prescription. Also her INR test was three weeks overdue.
Mrs A told the receptionist that she was going to stay with her sister in France for ten weeks and needed extra warfarin tablets. She also asked for antibiotics in case she got diarrhoea whilst away. She wanted to come back at 4pm to collect the prescriptions, as she was flying off the following day.
Dr L was concerned about this request and telephoned Medical Protection for advice.
Medicolegal adviser Dr Rachel Birch shares her advice…
The GMC states that doctors must “prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health, and are satisfied that the drugs or treatment serve the patient’s needs”. Doctors should also ensure that the treatment is compatible with any other treatments the patient is receiving.
The GMC also provides specific prescribing guidance, which advises:
- Doctors are responsible for the prescriptions that they sign and should be prepared to justify any decision to prescribe.
- Doctors do not have to prescribe treatments that they do not consider to be of overall benefit to patients, even if patients ask for such treatments. However, they should discuss the request with the patient, explain their reasons and advise the patient of their right to seek a second opinion.
- Doctors should, together with the patient, make an assessment of their condition before deciding to prescribe a medicine.
- Doctors should explain to patients the likely benefits and risks of treatments, including side effects.
- Advice should include how to take the medicine and how to adjust the dose.
- Doctors are responsible for the safe monitoring of a medication, including blood tests. If doctors prescribe for patients who are overseas, they should consider how the condition may be safely monitored. They should also consider whether they have appropriate professional protection to treat patients overseas.
Advice on Dr L’s case:
- The patient was overdue her INR test and this could present a risk if the patient was to go away for ten weeks.
- Consider INR monitoring abroad, since she is away for so long.
- Consider the GMC guidance and assess the patient in person. She may require an INR prior to her departure.
- Consider potential interactions of warfarin and antibiotics and whether the patient could be safely monitored abroad.
- Be aware of the risks of prescribing “just in case” medication – it would be safer and preferable for the patient to seek medical review if she were to become unwell abroad.
- It might be difficult for Dr L to justify prescribing “just in case” antibiotics, in the event that harm came to the patient abroad. She would not be able to make an adequate assessment of the patient at the time, and would have no way of knowing if the diarrhoea was due to bacteria or another cause.
Dr L arranged to see Mrs A at the end of her morning surgery. She took an INR blood test and arranged for the result to be telephoned back to the practice that afternoon. She explained her concerns about prescribing “just in case” antibiotics and advised the patient to seek medical review if she became unwell abroad.
She also advised the patient to have her INR checked whilst away by her sister’s GP. She provided the patient with a copy of her recent INR results and details of her warfarin dose, so that she could show this to her sister’s GP. She advised the patient to ensure that she had adequate health insurance. The patient thanked Dr L for her time in attending to her and telephoned the surgery prior to her holiday to obtain her INR result.
Writer and editor at MPS. MPS’s educational risk management workshops, ‘Mastering Professional Interactions’ and ‘Medical Records for GPs’ provide further information on the risks to patients and doctors when patient care passes between doctors, and on good record-keeping. They are free as a benefit of membership to MPS members too.