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Traps in repeat prescribing (99HDC01756)

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(99HDC01756, 29 June 2001)

General practitioner ~ Standard of care ~ Oral contraceptive ~ Repeat prescriptions ~ Rights 4(1), 4(2)

Through a series of repeat prescriptions over four years until her death of a pulmonary embolism, a woman in her early thirties had her prescription for the third-generation oral contraceptive pill Femodene renewed nine times. Numerous doctors at the medical centre she attended signed the prescriptions.

The woman was never explicitly advised to have her medication reviewed throughout this period, although her general practitioner had recommended an appointment for a "well woman check", but did not specify a check of her medication.

Women taking oral contraceptives should have their medication reviewed regularly, at least once a year as a minimum, to ensure that nothing has happened in the intervening period that indicates the medication is no longer clinically appropriate. Before renewing a prescription for an oral contraceptive, a practitioner has a responsibility to check whether a patient needs her medication reviewed. In most situations it would be sufficient to advise the patient of the need for a review and allow the patient to arrange this. It is good practice to confirm this advice in writing. In some situations it may be appropriate to prescribe a continuation of the medication for one month to ensure that cover is maintained pending a suitable appointment. Any discussions in these circumstances should be clearly recorded in the medical notes.

The general practitioner and the medical centre ought to have known that the patient's prescription needed to be reviewed and should have taken reasonable steps to review it, to ensure that its ongoing use was clinically appropriate. Reasonable steps include clearly informing the patient about the need for review of the medication, seeking an updated history, and performing a physical examination including specific tests to identify whether the patient has any new risk factors or contraindications. A review consultation also provides an opportunity for the doctor to update the patient with any relevant information, such as new risk information about third-generation pills.

It was held that the patient had not made an informed choice to refuse a medication review. She was never sufficiently informed of the need for such a review. It had not been made clear to her that a "well woman check" included a medication review, nor that such a review was needed in relation to the ongoing prescription of Femodene.

By continuing to prescribe medication for patients without taking reasonable steps to ensure that its ongoing use is clinically appropriate, doctors fail to provide services with reasonable care and skill and in compliance with relevant standards, in breach of Rights 4(1) and 4(2). This level of care, skill and compliance is required of every practitioner who signs repeat prescriptions. Medical centres should have a policy in place that ensures repeat prescriptions are issued only to patients who have had the appropriate checks carried out. Doctors should not sign repeat prescriptions, notwithstanding pressure from patients to do so, unless satisfied that the medication remains clinically appropriate.

The GP said that refusing to renew a prescription when a review was overdue is a "dogmatic way to retain a doctor's rights and medico-legal defence [and] is not always going to be in the patient's best interest". However, if a review of medication is overdue, it is entirely reasonable and appropriate for a doctor to require it before renewing the prescription. Doctors are not beholden to their patients' demands for services, including repeat prescriptions. The Code does not give patients, even if fully informed, the right to demand services. If a patient decides not to have a medication review, it is clinically inappropriate to renew the prescription. While patients cannot be required to undergo prerequisite reviews or checks, they equally cannot expect to receive medication on demand in these circumstances. Providing services in a manner consistent with patients' needs is not the same as providing inappropriate services in accordance with patients' wishes.

The centre indicated that it has made changes to its policy and practice to ensure that patients have regular review of ongoing medication, and only one repeat between visits to the doctor.