Woman took excessively high dose of medication for three months after GP failed to check prescriptions

What happened

In spring 2013 Ms G went to hospital with a weakness in her left arm. Staff suspected that she had had a stroke. They gave her a single dose of 300mg clopidogrel (a blood thinning drug) to treat this, and discharged her with an appointment at the stroke clinic. When staff at the stroke clinic reviewed Ms G, they prescribed her 75mg clopidogrel, one tablet to be taken daily.

In summer, Ms G asked for a repeat prescription of 75mg clopidogrel from her GP Practice. The Practice prescribed her 300mg clopidogrel, one tablet to be taken daily. The Practice issued two repeat 300mg prescriptions the next month. When Ms G returned to the Practice for a further repeat prescription, the Practice nurse arranged for the prescription of clopidogrel to be changed from 300mg to 75mg.

Ms G complained to us about the Practice prescribing the incorrect dose. She also complained that the Pharmacy had repeatedly dispensed the incorrect dose.

What we found

We upheld Mrs G's complaint about the Practice. It mistakenly prescribed Ms G 300mg clopidogrel three times instead of the 75mg clopidogrel she should have had. Ms G's GP's failure (or the failure of any other practitioner registered to prescribe medication at the Practice) was the root cause of the medication error.

The new prescribing protocol that the Practice set up – to make sure that all repeat prescriptions would be tagged and authorised by the GP in future – showed that it had learnt from what had happened. However, we did not think that it had explained what had happened in its response to Ms G. It had also not given Ms G an appropriate acknowledgment and apology.

We also considered that there was an increased risk to Ms G's health for a period of three months and it is possible that the bruising, dizziness and gastrointestinal problems she suffered were caused by the excessive dose of clopidogrel.

We did not uphold the complaint about the Pharmacy. There was no documented evidence to support the Pharmacy's explanation that it had queried the prescription of 300mg clopidogrel with Ms G's Practice. However, as this was a non–standard dose that would need to be specially ordered by the Pharmacy, we concluded that, on balance, this conversation did happen and it was therefore appropriate to have dispensed the prescription.

The Pharmacy apologised to Ms G for dispensing too high a dose of clopidogrel to her three times. It also discussed this incident with its staff, and amended its standard operating policy to include instructions for staff to discuss any non–standard doses with the patient (if this is not already documented) and to record those discussions.

We considered this to be an appropriate and proportionate remedy to Ms G's complaint about the Pharmacy.

Putting it right

The Practice acknowledged and apologised for its failings, and the GP agreed to discuss what had happened with his responsible officer. The Practice paid Ms G £250 compensation for the potential threat to her health and her subsequent loss of confidence in the Practice.