Discussions on Private-Rx, an internet discussion forum for pharmacists, have prompted a computer supplier to make changes to its patient medication record software.
The discussions centred around a National Health Service inquiry into the death of a patient. The patient had been prescribed methotrexate tablets weekly but ended up taking them daily and later died as a result of "a cascade of errors". Cambridgeshire health authority recently posted details of the inquiry and its findings on its website (www.cambs-ha.nhs.uk/publications).
Among the recommendations of the inquiry were that changes should be made to software for general medical practitioners and community pharmacists to warn them of the weekly dose. The case was highlighted and discussed on Private-Rx (www.private-rx.net). As a result of the discussions, NDC will be updating its PMR software at the end of the month so that pharmacists receive additional information when dispensing methotrexate. The patient information leaflet produced by the system has also been amended to include clear advice about dosage for patients.
Mr Peter Neal (director of client services, NDC) said on August 7: "As a pharmacist, I regularly use the forum and in this case I found the discussions on methotrexate invaluable when advising on the enhancements to our system."