Handling Prescribing Errors: Duty of Candour and Incident Response

No prescriber is immune to error. Despite rigorous training, robust clinical systems, and careful practice, prescribing errors will occasionally occur. What defines your professionalism is not perfection but how you respond when something goes wrong. Your response in the first minutes and hours after discovering an error determines patient outcomes, your professional standing, and the culture of safety in your practice.

Understanding your legal and professional obligations around prescribing errors, including the duty of candour, is not optional. It is a fundamental requirement for every pharmacist independent prescriber working in private practice.

Prescribing Errors Happen: What to Do Immediately

When you discover or suspect a prescribing error, patient safety must be your immediate and overriding priority. Everything else, documentation, reporting, reflection, comes afterwards.

Clinical Assessment of Harm

First, determine whether the patient has come to harm or is at risk of harm. Has the patient taken the incorrectly prescribed medication? If so, what is the clinical significance? Some errors, such as a minor dose discrepancy of a low-risk medication, may cause no harm. Others, such as prescribing a medication to which the patient has a documented allergy, require urgent clinical intervention.

Immediate Actions

• Contact the patient immediately if they may have received or taken the incorrectly prescribed medication
• Seek clinical advice from a colleague, the National Poisons Information Service, or secondary care if the error could cause significant harm
• Arrange medical assessment for the patient if there is any possibility of adverse effects
• Correct the prescription and ensure the patient receives the correct medication if treatment is still required

Document every action you take, including times, conversations, and clinical decisions. This contemporaneous record is essential for incident reporting and any subsequent investigation.

Duty of Candour: Legal Obligation to Be Open

The duty of candour is both a professional and legal obligation. For CQC-registered services, it is a regulatory requirement under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. For all healthcare professionals, it is a professional standard enforced by your regulator.

What the Duty of Candour Requires

When a notifiable safety incident occurs, you must tell the patient (or their representative) as soon as reasonably practicable. You must provide a truthful account of what happened, explain what you are doing to investigate and prevent recurrence, and offer an apology. This apology is not an admission of liability; it is a professional acknowledgement that something went wrong.

The Professional Standard

The GPhC Standards for Pharmacy Professionals require honesty and transparency. Standard 6 states that pharmacy professionals must behave in a professional manner, which includes being open when things go wrong. Failing to disclose an error, even if no harm resulted, is a more serious professional failing than the error itself.

Openness builds trust. Patients who are told honestly about errors are less likely to make formal complaints and more likely to continue trusting their healthcare provider.

Incident Reporting: Internal and External Requirements

Proper incident reporting serves multiple purposes. It ensures the error is documented, investigated, and learned from. It contributes to national safety data. And it demonstrates your commitment to continuous improvement.

Internal Incident Logging

Every prescribing error, regardless of whether it reached the patient or caused harm, should be recorded in your internal incident log. Include the date and time, the nature of the error, how it was discovered, what actions were taken, and the outcome for the patient. Near-miss events, where an error was identified before it reached the patient, are equally important to record.

External Reporting Obligations

• National Reporting and Learning System (NRLS): Report patient safety incidents through the NRLS, now transitioning to the Learn from Patient Safety Events (LFPSE) service
• GPhC: Self-referral may be appropriate if the error raises fitness to practise concerns, though not all errors require this
• CQC: If you are CQC-registered, certain incidents must be reported as statutory notifications
• Your indemnity provider: Notify your insurer promptly of any incident that could give rise to a claim

Patient Communication After an Error

Communicating with a patient after an error is one of the most challenging conversations you will have as a prescriber. Preparation, honesty, and empathy are essential.

How to Have the Conversation

Choose an appropriate setting, whether in person or via a private phone call. Be direct and honest about what happened. Use plain language rather than clinical jargon. Explain what the error was, how it occurred if you know, what you have done to address it, and what steps you are taking to prevent it happening again.

The Apology

Offer a sincere, unreserved apology. The Compensation Act 2006 clarifies that an apology does not constitute an admission of negligence. Saying sorry is the right thing to do professionally and ethically. Patients deserve to hear it, and it is a legal requirement under the duty of candour for notifiable incidents.

Follow up the verbal conversation with a written summary. This provides the patient with a record of what was discussed and demonstrates your transparency.

Root Cause Analysis and Prevention

Understanding why an error occurred is more valuable than simply recording that it happened. Root cause analysis examines the systemic factors that contributed to the error, rather than focusing solely on individual blame.

Systematic Investigation

Examine the circumstances surrounding the error. Was it a knowledge gap, a communication failure, a systems issue, or a combination of factors? Consider workload, time pressure, interruptions, technology failures, and environmental factors. Most errors result from a chain of contributing factors rather than a single cause.

Systems Versus Individual Failures

Modern patient safety science recognises that most errors are systems failures rather than individual incompetence. While personal accountability remains important, focusing on systems improvements prevents recurrence more effectively than punitive responses. Ask what can be changed in the process to make this error less likely, rather than simply asking who made the mistake.

Implement changes based on your findings and monitor their effectiveness. Share learnings with colleagues to prevent similar errors across your practice.

Professional and Emotional Support After Incidents

Prescribing errors affect prescribers as well as patients. The second victim phenomenon is well documented. Feelings of guilt, anxiety, self-doubt, and fear of consequences are normal responses to being involved in a patient safety incident.

Seeking Support

• Peer support: Speak to a trusted colleague who understands the pressures of prescribing practice
• Professional networks: Many prescriber networks offer peer support groups and mentoring
• Pharmacist Support: The charity provides confidential support for pharmacists experiencing professional difficulties
• Your indemnity provider: Many providers offer helplines staffed by clinical advisers who can provide immediate guidance

Moving Forward

An error does not define you as a prescriber. What defines you is how you respond: with honesty, accountability, and a commitment to learning. The vast majority of prescribers who experience errors continue to practise safely and effectively, often with heightened awareness and improved systems.

RxSure’s platform provides built-in clinical decision support, audit trails, and safety features designed to reduce prescribing errors and support prescribers in delivering safe, effective care. Technology cannot eliminate human error, but it can create systems that catch errors before they reach patients.