Indicators rated as appropriate for assessing the safety of prescribing in general practice
| Indicator | Risk of harm (1 = low, 2 = moderate, 3 = high, 4 = extreme) |
|---|---|
| A: Cardiovascular and respiratory disease | |
| 1. Aspirin or clopidogrel prescribed to people with previous peptic ulcer or gastrointestinal bleed without gastroprotectiona | 3 |
| 2. Prescription of aspirin at a dose >75mg daily for ≥1 month in a patient aged >65 years | 2 |
| 3. Prescription of digoxin at a dose >125 μg daily in a patient with renal impairment (for example, CKD 3 or worse) | 3 |
| 4. Prescription of digoxin at a dose of greater than 125 μg daily for a patient with heart failure who is in sinus rhythm | 3 |
| 5. Prescription of diltiazem or verapamil in a patient with heart failurea | 3 |
| 6. Prescription of a beta-blocker to a patient with asthma (excluding patients who also have a cardiac condition, where the benefits of beta-blockers may outweigh the risks)a | 3 |
| 7. Prescription of a long-acting beta-2 agonist inhaler to a patient with asthma who is not also prescribed an inhaled corticosteroid | 3 |
| B: Central nervous system (including analgesics) | |
| 8. Prescription of a benzodiazepine or Z drug for ≥21 days, in a patient aged >65 years, | 3 |
| who is not receiving benzodiazepines or Z drugs on a long-term basis | |
| 9. Initiation of prescription of benzodiazepine or Z drugs for ≥21 days in a patient aged >65 years with depression | 3 |
| 10. Antipsychotics prescribed for >6 weeks in the over 65s with dementia but not psychosisa | 3 |
| 11. Amitriptyline at dose >75mg prescribed to a patient with heart failure, arrhythmia, heart block. or postural hypotension | 3 |
| 12. Prescription of aspirin to a child aged ≤16 years | 2 |
| 13. Bupropion prescribed to a patient with epilepsy | 3 |
| C: Anti-infective agents | |
| 14. Prescription of mefloquine to a patient with a history of convulsionsa | 3 |
| D: Endocrine and metabolic | |
| 15. Glitazone prescribed to patient with heart failurea | 3 |
| 16. Metformin prescribed to a patient with renal impairment where the eGFR is ≤30ml/mina | 4 |
| 17. Oral prednisolone prescribed at a dose ≥7.5mg daily for more than 3 months to the over 65s without co-prescription of osteoporosis-preventing treatmentsa | 3 |
| 18. Modified-release potassium supplements prescribed to a patient with a history of peptic ulcer disease | 2 |
| E: Women’s health and urinary disorders | |
| 19. Prescription of a combined hormonal contraceptive to a woman with a history of venous or arterial thromboembolism | 3 |
| 20. Prescription of oral or transdermal oestrogens to a woman with a history of breast cancer | 3 |
| 21. Prescription of oral or transdermal oestrogen without a progestogen in a woman with an intact uterus | 3 |
| 22. Prescription of a combined hormonal contraceptive to a woman aged ≥35 years who is a current smoker | 3 |
| 23. Prescription of a combined hormonal contraceptive to a woman with a body mass index of ≥40a | 3 |
| F: Immunosuppression | |
| 24. Methotrexate prescriptions should state ‘weekly’ | 3 |
| 25. Methotrexate 2.5/10mg co-prescription | 3 |
| 26. Methotrexate prescribed without folic acid | 3 |
| G: Musculoskeletal | |
| 27. Concurrent use of two NSAIDS for more than 2 weeks (not including low-dose aspirin) | 3 |
| 28. Prescription of an NSAID, without co-prescription of an ulcer-healing drug, to a patient with a history of peptic ulcerationa | 4 |
| 29. Prescription of an NSAID in a patient with heart failurea | 3 |
| 30. Prescription of an NSAID in a patient with chronic renal failure with an eGFR <45a | 4 |
| 31. Allopurinol prescribed at a dose of >200mg/day to patients with renal impairment (eGFR <30 or CKDA)a | 3 |
| H: Hazardous co-prescriptions and allergy | |
| 32. Prescription of warfarin and aspirin in combination (without co-prescription of gastroprotection)a | 3 |
| 33. Concurrent use of warfarin and any antibiotic without monitoring the INR within 5 daysa,b | 4 |
| 34. Prescription of warfarin in combination with an oral NSAID | 3 |
| 35. Prescription of a phosphodiesterase type-5 inhibitor, for example sildenafil, to a patient who is also receiving a nitrate or nicorandila,c | 3 |
| 36. Co-prescription of lithium with thiazide diuretic | 3 |
| 37. Prescription of a potassium salt or potassium-sparing diuretic (excluding aldosterone antagonists) to a patient who is also receiving an ACE inhibitor or angiotensin II receptor antagonista | 3 |
| 38. Prescription of verapamil to a patient who is also receiving a beta-blocker | 3 |
| 39. Co-prescription of itraconazole with simvastatin, or with atorvastatin at a dose ≥80mga,c | 3 |
| 40. Co-prescription of trimethoprim with methotrexate for >7 daysa | 3 |
| 41. Prescription of clarithromycin or erythromycin to a patient who is also receiving simvastatin, with no evidence that the patient has been advised to stop the simvastatin while taking the antibiotica | 3 |
| 42. Prescription of a penicillin-containing preparation to a patient with a history of allergy to penicillin | 4 |
| I: Laboratory test monitoring | |
| 43. Patients aged >75 years on loop diuretics who have not had a U+E in the previous 15 monthsa | 3 |
| 44. Prescription of amiodarone without a record of liver function being measured in the previous 9 months | 3 |
| 45. Prescription of amiodarone without a record of thyroid function being measured within the previous 9 months | 3 |
| 46. Prescription of an ACE inhibitor or angiotensin II receptor antagonist without a record of renal function and electrolytes being measured prior to starting therapy | 3 |
| 47. Patients on an ACE inhibitor or angiotensin II receptor antagonist who have not had a U+E in the previous 15 monthsa | 3 |
| 48. Prescription of warfarin to a patient without a record of INR having been measured within the previous 12 weeks (excluding patients who self-monitor) | 4 |
| 49. Prescription of a statin without an ALT taken prior to starting treatment | 3 |
| 50. Prescription of a statin without an ALT taken prior to starting treatment and within 3 months of starting treatment | 3 |
| 51. Prescription of lithium without a record of a lithium level being measured within the previous 6 monthsa | 3 |
| 52. Metformin without yearly serum creatinine | 3 |
| 53. Use of a hypothyroid agent without monitoring relevant thyroid function tests within 2–4 months of initiation or dosage change and at least every 15 months thereafter | 3 |
| 54. Prescription of methotrexate without a record of a full blood count within the previous 3 months | 3 |
| 55. Prescription of methotrexate without a record of liver function having been measured within the previous 3 months | 3 |
| 56. Allopurinol without baseline urea, electrolytes, creatinine and eGFR | 2 |
↵a For 23 items (19 high risk and 4 extreme risk) 80% or more of the responders rated the indicator as high or extreme risk.
↵b Consensus reached for assessing the safety of prescribing of practices, but not individual GPs.
↵c Consensus reached for assessing the safety of prescribing of individual GPs, but not practices. ACE inhibitor = angiotensin-converting enzyme inhibitor. ALT = alanine transferase. CKD = chronic kidney disease. eGFR = estimated glomerular filtration rate. INR = International Normalised Ratio. NSAID = non-steroidal anti-inflammatory drug. U+E = urea and electrolytes.