FDBE aims to cut drug dosing errors

The NPSA, established as a Special Health Authority in July 2001, aims to improve the safety of patients taking oral methotrexate by incorporating new, specific warning prompts within clinical systems to reduce the risk of incorrect dosing.

The NPSA’s Safe Medication Practice Team is working closely with FDBE, In Practice Systems, EMIS and other primary care system suppliers to help introduce further safeguards to their prescribing and dispensing applications on drugs such as oral methotrexate.

FDBE’s Multilex Drug Data File (Multilex DDF) is integrated into a significant proportion of GP clinical systems and across the healthcare community.

Oral methotrexate is a well established, effective treatment for several different types of rheumatic and psoriatic disease. However, the weekly prescribing requirements of oral methotrexate are unusual and can be easily misinterpreted by both patients and healthcare professionals, resulting in potentially fatal daily dosing.

NPSA has reported that serious dosing errors have been documented over a ten year period which have resulted in twenty five patient deaths and twenty-six cases of serious long-term harm.

FDBE says it will incorporate changes within Multilex DDF to support the NPSA’s recommendations. These will include highlighting methotrexate whenever it is selected to prescribe or dispense. The firm will also amend its systems to provide appropriate warning messages to help guide clinicians in prescribing and managing the drug and patient within accredited guidelines.

Wendy Harris, senior pharmacist, Safe Medication Practice and Project Lead at the NPSA said, “This is an important development and one which exemplifies the NPSA’s aim to design out opportunities for error, making it harder for a clinician to make a mistake.  The changes to IT systems form one part of a package of solutions to prevent dosing errors with oral methotrexate."

Robin Glasspoole, product manager of FDBE said: “Nothing is closer to our company’s philosophy and strategy than patient safety – we hope this will be the first of many NPSA recommendations that we can take forward."

The project will commence immediately and FDBE says it will work with both their general practice and retail pharmacy customers to encourage the new functionality to be implemented this year wherever possible.