There are ‘considerable’ opportunities to improve primary care prescribing safety and it is time that prescribing safety becomes a priority in primary care, according to the authors of this study. They analysed data from 315 Scottish general practices and found that nearly 14% of patients who were defined as being vulnerable to adverse drug events had received one or more high-risk prescriptions in the last year.
Vulnerability was assessed on the basis of age, pre-existing condition such as heart failure or chronic kidney disease, or existing prescription of a drug with potential for interaction such as warfarin or diuretics. Indicators for high-risk prescribing were defined on the basis of safety alerts, national clinical guidelines, the BNF and prescribing advice. What this means is that although few of these prescriptions were absolutely contraindicated and may have been appropriate, explicit guidance mostly underpinned by a solid evidence base existed that they carried significant risk of harm and should be avoided in most situations. Of those patients prescribed 11 or more drugs in the long term, more than a quarter received a high risk prescription, and increasing age also increased the risk, up to the age of about 80. There was wide variation in high-risk prescribing between practices, with none of the variables examined accounting for this.
The authors suggest that drug reviews could be targeted at those receiving high risk prescriptions defined using these indicators, so that their appropriateness can be the subject of clinical judgement. Despite the significant harm caused by prescribing, these results suggest that prescribing improvement activity does not focus enough on safety.
Guthrie B et al. High risk prescribing in primary care patients particularly vulnerable to adverse drug events: cross sectional population database analysis in Scottish general practice. BMJ 2011; 342:d3514.