Prescribing Medication with Prefixes

Vision has been made aware of a clinical safety risk relating to potentially selecting an incorrect medication for prescribing when the name of the medication is composed of 2 parts with a prefix before the root word (e.g. depo provera or co amoxiclav). 

Using these examples, when ‘depo provera’ is entered into Vision as a drug name search, ‘depo‐medrone’ may be subsequently displayed for selection. Similarly, when ‘co amoxiclav’ is entered, co‐amilforuse may be displayed. This occurs if both medications are included in the Vision practice formulary or if there is no practice formulary selected. This can affect any medication with a prefix and has previously resulted in the wrong medication being selected and erroneously prescribed and administered. 

Vision intends to make changes to their prescribing system to prevent these errors from occurring, going forward. Until Vision has implemented such changes, we would ask that prescribers at GP practices exercise vigilance and caution when prescribing medication with prefixes in order to try and prevent future prescribing errors. In the meantime, the following two workarounds are recommended as possible options for interim mitigation against the risk to patient safety: 

- Amend the prescribing formulary so the formulary only includes medication with one similar prefix. For example, in in order to ensure depo‐provera is displayed when ‘depo provera’ is typed, remove depo-medrone from the formulary.

- Ensure that any prefix is always joined to the root word with a hyphen when searching for the desired medication. For example, as the drug name search enter ‘depo‐provera’ and not ‘depo provera’; ‘co‐amoxiclav’ and not ‘co amoxiclav’.