Clinical pharmacy service practice in a Chinese tertiary hospital

Clinical pharmacy service is focused on the rationality and safety of medication therapy. Clinical pharmacists play an important role in designing therapeutic regimen, preventing medication errors, reducing the incidence of adverse drug reaction, and saving medical costs. Although clinical pharmacy service in China is in its early stage, its development is rapid. In this manuscript, the working model of clinical pharmacists in a Chinese tertiary hospital is introduced, including ward rounds, consultation, stewardship of antimicrobial therapy, drug adverse reaction monitoring, therapeutic drug monitoring, clinical pharmacokinetics and pharmacogenetics, and training system. With the efforts of clinical pharmacists, there will be a significant increase in the optimization of medication therapy and a notable reduction in preventable adverse drug events as well as health-care cost in China.

NCPDP recommendations for dose accumulation monitoring in the inpatient setting: Acetaminophen case model, version 1.0

PURPOSE

Best practices and guidance are provided for improved electronic detection and alerting of inadvertent supratherapeutic cumulative doses of acetaminophen and other medications with narrow therapeutic ranges in inpatient settings.

SUMMARY

Despite the use of medication safety technologies, overdosage and associated sentinel events continue to be serious problems in many inpatient settings. The tools needed to monitor and employ dose alerts, accumulators, and warning systems are available to reduce inadvertent overdose. Required are staff training and the implementation of processes that provide guidance and documentation of the drug reconciliation process from admittance to discharge for safe patient passage through the various transitions of care. Recommendations to achieve optimal patient safety outcomes include the adoption and integration of available technologies with full functionality configured to meet the institution's policies and processes, initial training and retraining of all staff who use these systems, continuing education of the patient care staff on the dosing safety requirements, and assigning a prominent role to the clinical pharmacist in the entire drug-use and reconciliation process.

CONCLUSION

The key factors contributing to inadvertent overdosage in inpatient settings include a lack of recognition of recommended maximum daily dosages; failure to optimally communicate medication information at transitions of care; failure to optimally implement medication safety technologies, particularly dose accumulator calculation features and associated alerts; and alert fatigue and override.

Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

OBJECTIVES

Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge.

SETTING

An acute 400-bedded teaching hospital in London, UK.

PARTICIPANTS

The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months.

INTERVENTIONS

Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives.

RESULTS

Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems.

CONCLUSIONS

New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.

Impact of the Pharmacy Practice Model Initiative on Clinical Pharmacy Specialist Practice

This paper describes the goals of the American Society of Health-System Pharmacists' Pharmacy Practice Model Initiative (PPMI) and its recommendations for health-system pharmacy practice transformation to meet future patient care needs and elevate the role of pharmacists as patient care providers. PPMI envisions a future in which pharmacists have greater responsibility for medication-related outcomes and technicians assume greater responsibility for product-related activities. Although the PPMI recommendations have elevated the level of practice in many settings, they also potentially affect existing clinical pharmacists, in general, and clinical pharmacy specialists, in particular. Moreover, although more consistent patient care can be achieved with an expanded team of pharmacist providers, the role of clinical pharmacy specialists must not be diminished, especially in the care of complex patients and populations. Specialist practitioners with advanced training and credentials must be available to model and train pharmacists in generalist positions, residents, and students. Indeed, specialist practitioners are often the innovators and practice leaders. Negotiation between hospitals and pharmacy schools is needed to ensure a continuing role for academic clinical pharmacists and their contributions as educators and researchers. Lessons can be applied from disciplines such as nursing and medicine, which have developed new models of care involving effective collaboration between generalists and specialists. Several different pharmacy practice models have been described to meet the PPMI goals, based on available personnel and local goals. Studies measuring the impact of these new practice models are needed.

Current status and future prospects of the development of clinical Pharmacy in China: A SWOT analysis

In many industrialized countries, clinical pharmacy has developed into a separate discipline and become a vital part of inpatient care in hospitals. However, as compared to many established branches of medicine, clinical pharmacy is still in its infancy, with much room for growth, improvement, and recognition by both the medical community and patients. In this study, a widely-recognized development strategy analysis tool, Strength, Weakness, Opportunity and Threat (SWOT), was used to systematically address several key issues to the development of clinical pharmacy in China. This analysis aims to provide feasible recommendations for the development of clinical pharmacy in China by identifying current problems and growth opportunities. Full development of clinical pharmacy as a mature clinical discipline will help promote the rational use of drugs by both clinicians and patients and lead to enhanced drug efficacy and safety.

Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes

BACKGROUND

Cellulitis is a common infection with wide variation of clinical care.

OBJECTIVE

To implement an evidence-based care pathway and evaluate changes in process metrics, clinical outcomes, and cost for cellulitis.

DESIGN

A retrospective observational pre-/postintervention study was performed.

SETTING

University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah.

PATIENTS

All patients 18 years or older admitted to the emergency department observation unit or hospital with a primary diagnosis of cellulitis.

INTERVENTION

Development of an evidence-based care pathway for cellulitis embedded into the electronic medical record with education for all emergency and internal medicine physicians.

MEASUREMENTS

Primary outcome of broad-spectrum antibiotic use. Secondary outcomes of computed tomography/magnetic resonance imaging orders, length of stay (LOS), 30-day readmission, and pharmacy, lab, imaging, and total facility costs.

RESULTS

A total of 677 visits occurred, including 370 visits where order sets were used. Among all patients, there was a 59% decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), 23% decrease in pharmacy cost (P = 0.002), and 13% decrease in total facility cost (P = 0.006). Compared to patients for whom order sets were not used, patients for whom order sets were used had a 75%, 13%, and 25% greater decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), clinical LOS (P = 0.041), and pharmacy costs (P = 0.074), respectively.

CONCLUSION

The evidence-based care pathway for cellulitis improved care at an academic medical center by reducing broad-spectrum antibiotic use, pharmacy costs, and total facility costs without an adverse change in LOS or 30-day readmissions.

The impact of electronic prescribing systems on pharmacists' time and workflow: protocol for a time-and-motion study in English NHS hospitals

INTRODUCTION

Electronic prescribing (ePrescribing) systems are rapidly being introduced into National Health Systems (NHS) hospitals in England following their widespread earlier adoption into primary care settings. Such systems require substantial changes in the way pharmacists organise their work and perform their roles. There is however as yet limited evidence on the extent to which these changes may support or compromise efficient and safe working practices by pharmacists. Identifying and quantifying these changes, and their effects, is central to informing system and work practice design, as well as informing training and implementation processes. This protocol describes a study to measure the impact of ePrescribing systems on pharmacists' time and workflow.

METHODS AND ANALYSIS

A direct observational controlled pre-post implementation time-and-motion study will be conducted in six wards at one NHS Trust over two observational periods. Pharmacists will be shadowed and details of all work tasks performed will be collected and time-stamped. Task distribution, frequency and duration will be measured and changes in these measures preimplementation and postimplementation, and between control and intervention wards will be measured. Interviews with pharmacists will investigate their perceptions of the impact of the ePrescribing systems on their work and will be conducted in both periods. The extent to which pharmacists' expectations of the impact of the ePrescribing systems on their work with postimplementation reports will be qualitatively explored, as will any differences between perceptions and results from the time-and-motion analysis.

ETHICS AND DISSEMINATION

Institutional research ethics approval has been obtained from The University of Edinburgh. Local approval from the participating NHS Trust and informed consent from participating pharmacists have been obtained, while also complying with local governance requirements. The results of the study will be presented at conferences, published in peer-reviewed journals, and shared with members of our Patient and Public Involvement Group, to facilitate wider dissemination.

Implementation of Pharmaceutical Practice Guidelines by a Project Model Based: Clinical and Economic Impact

All around the world a few studies have been found on the effect of guideline implementation on direct medications' expenditure. The goal of this study was to evaluate cost savings of guideline implementation among patients who had to receive 3 costly medications including albumin, enoxaparin, and pantoprazole in a tertiary hospital in Shiraz, Iran.An 8-month prospective study was performed in 2 groups; group 1 as an observational group (control group) in 4 months from June to September 2014 and group 2 as an interventional group from October 2014 to January 2015.For group 1 the pattern of costly medications usage was determined without any intervention. For group 2, after guideline implementation, the economic impact was evaluated by making comparisons between the data achieved from the 2 groups.A total of 12,680 patients were evaluated during this study (6470 in group 1; 6210 in group 2). The reduction in the total value of costly administered drugs was 56% after guideline implementation. Such reduction in inappropriate prescribing accounts for the saving of 85,625 United States dollars (USD) monthly and estimated 1,027,500 USD annually.Guideline implementation could improve the adherence of evidence-based drug utilization and resulted in significant cost savings in a major teaching medical center via a decrease in inappropriate prescribing of costly medications.

Development and multi-centre evaluation of a method for assessing the severity of potential harm of medication reconciliation errors at hospital admission in elderly

BACKGROUND

Medication reconciliation is a powerful process to correct medication errors (ME) resulting from miscommunicated information at transitions of care. This study aims to develop and evaluate a scoring method for assessing the severity of potential harm of ME intercepted by medication reconciliation at hospital admission in elderly.

METHODS

The development of the scoring method was based on a literature search and the creation of a list of high-risk drugs used in outpatient care. The evaluation of the method was carried out in 7 French hospitals and was based on two criteria: the inter-rater reliability and acceptability. The assessment of the inter-rater reliability was based on intra-class correlation coefficient (ICC) calculations. Each hospital prospectively enrolled the 10 first patients aged 65 or older presenting with at least one ME. Seven blocks of 10 patients were formed. After randomization, each block was rated by practitioners from 3 hospitals. The assessment of the acceptability was based on a satisfaction questionnaire.

RESULTS

A clinical algorithm was developed. The inter-rater reliability of the method was validated by the overall agreement of the 7 hospitals ratings. The agreement was at least substantial (ICC>0.60) and in most of cases almost perfect (ICC>0.80). The acceptability of the method was judged as satisfactory.

CONCLUSION

This multi-centre project has validated an instrument for assessing the severity of potential harm of ME intercepted by medication reconciliation. This will allow studies to be conducted with large cohorts of patients in order to develop epidemiological databases of ME of potential clinical significance.

[Preliminary study for the implementation of standardized rounded doses of cytotoxic druqs]

BACKGROUND

"Dose-banding" is a concept of cytotoxic drugs standardization allowing the preparation in advance of standardized rounded doses (SRD covering the most frequently prescribed doses rounded to +/-5%. Standard doses will be prepared in advance by batch in order to increase production capacity and at the same time to regulate pharmacy workflow as well as to reduce patient waiting time.

PURPOSE

To identify anticancer drugs suitable for dose banding and to fix standardized doses.

METHODS

The interesting molecules are first selected in accordance with several criteria: preparations frequency, long-term physicochemical stability after reconstitution, repetition of the prescribed doses and savings opportunity. The selected molecules were: Carboplatin, Cetuximab, Cisplatin, Cyclophosphamide, Doxorubicin, 5-Fluorouracil, Gemcitabine, Oxaliplatine, Paclitaxel, Rituximab, Trastuzumab and Vinorelbine. We established an inventory of the prescriptions retrospectively for a period of six months in order to highlight the most often prescribed doses. For the analysis, we fixed bands with a standard deviation of +/- 5%, 7% and +/- 10%.

RESULTS

Standardization of doses of chemotherapy was deemed interesting if > or =60% of the doses were standardisable with a maximum of five SRD and a minimum of one delivery per week, in order to guarantee a good turnover of the batch. A maximum of 5% standard deviation is added to those three criteria, the deviation currently accepted among our medical staff. After analyzing 3506 prescriptions, 7 molecules are eligible: Doxorubicine, 5-Fluorouracil infusion, 5-Fluorouracil pump, Gemcitabine, Paclitaxel, Rituximab, Trastuzumab and Vinorelbine, with a percentage of standardisation of 77% [SRD: 30 mg), 61% [SRD: 700 mg, 750 mg, 800 mgl, 75% (SRD: 4000 mg, 4500 mg, 5000 mg), 72% [SRD: 1600 mg, 1800 mg, 2000 mg), 61% [SRD: 140 mg, 150 mg, 160 mgl, 64% (SRD: 600 mg, 700 mg, 750 mg], 71% (SRD: 350 mg, 400 mg. 450 mgl et 62% [SRD: 40 mg, 50 mg] respectively.

CONCLUSION

This preliminary study allows us to consider implementing the dose banding concept in order to optimize the chemotherapy circuit at our institution.

Credentialing and privileging of pharmacists: a resource paper from the Council on Credentialing in Pharmacy

Processes for the credentialing and privileging of health professionals are of increasing importance and value to the U.S. health care system and to society. As efforts continue to provide and reward more efficient, affordable, and higher quality health care (the "triple aim" described by Berwick et al.1), the ability to ensure the capabilities and competence of the health professionals, including pharmacists, who practice within an increasingly complex and sophisticated system has become both more relevant and essential. Currently, all U.S.-educated pharmacists attain a fundamental set of credentials to qualify to enter practice-an accredited professional pharmacy degree and a license awarded upon successful completion of a national postgraduation examination administered by the National Association of Boards of Pharmacy on behalf of state boards of pharmacy. This process provides an established framework to assure stakeholders of the ability of pharmacists to provide care and services that reflect sound, entry-level practice. However, evolving patient care and health system needs and demands have heightened the requisite skills needed by pharmacists to deliver more complex services. Ongoing professional development and competency assessment are integral parts of health professionals' expectations to maintain a contemporary practice. This resource guide on the credentialing and privileging of pharmacists has been developed to supplement the Council on Credentialing in Pharmacy (CCP)a Guiding Principles for Post-licensure Credentialing of Pharmacists2 and to assist those who are introducing or enhancing a credentialing and privileging system for pharmacists within their health care settings. CCP does not provide the guide for use as a standard of practice nor intends to represent the content as best or expected practices.

Adequacy of antidote stocking in British Columbia hospitals: The 2005 Antidote Stocking Study

Background:

Inadequate hospital stocking and the unavailability of essential antidotes is a worldwide problem with potentially disastrous repercussions for poisoned patients. Research indicates minimal progress has been made in the resolution of this issue in both urban and rural hospitals. In response to this issue the British Columbia Drug and Poison Information Centre developed provincial antidote stocking guidelines in 2003. We sought to determine the compliance with antidote stocking in BC hospitals and any factors associated with inadequate supply.

Methods:

A 2-part survey, consisting of hospital demographics and antidote stocking information, was distributed in 2005 to all acute care hospital pharmacy directors in BC. The 32 antidotes examined (21 deemed essential) and the definitions of adequacy were based on the 2003 BC guidelines. Availability was reported as number of antidotes stocked per hospital and proportion of hospitals stocking each antidote. For secondary purposes, we assessed factors potentially associated with inadequate stocking.

Results:

Surveys were completed for all 79 (100%) hospitals. A mean of 15.6 ± 4.9 antidotes were adequately stocked per hospital. Over 90% of hospitals had adequate stocks ofN-acetylcysteine, activated charcoal, naloxone, calcium salts, flumazenil and vitamin K; 71%–90% had adequate dextrose 50% in water (D50W), ethyl alcohol or fomepizole, polyethylene glycol electrolyte solution, protamine sulfate, and cyanide antidotes; 51%–70% had adequate folic acid, glucagon, methylene blue, atropine, pralidoxime, leucovorin, pyridoxine, and deferoxamine; and &lt;50% had adequate isoproterenol and digoxin immune Fab. Only 7 (8.9%) hospitals sufficiently stocked all 21 essential antidotes. Factors predicting poor stocking included small hospital size (p &lt; 0.0001), isolation (p = 0.01) and rural location (p &lt; 0.0001).

Conclusion:

Although antidote stocking has improved since the implementation of the 2003 guidelines, essential antidotes are absent in many BC hospitals. Future research should focus on determining the reasons for this situation and the effects of corrective interventions.

Discharge Time Out: An Innovative Nurse-Driven Protocol for Medication Reconciliation

An innovative method for discharge medication reconciliation was developed by nurses to ensure safe transition of care and improved patient outcomes. The discharge time-out process has empowered nurses to take a more active role in discharging their patients, and has fostered a more collaborative relationship between nurses and physicians.

[A new joint approach to drug management: clinical pharmacy services and risk management unit]

INTRODUCTION

According to the "To Err is Human" report, medication-related errors are common in medicine and may have several and different effects. Clinical Pharmacy is a leading worldwide established pharmacy service which has been improving the quality of care for the last 30 years. The accumulated experience shows improved quality of care, improved patient safety and economic benefit. These understandings led to the definition and expansion of the Clinical Pharmacist Intervention Program and a joint project with the Risk Management Unit was created.

METHODS

A characterization process was conducted, parameters were defined for monitoring and surveillance and interventions were devised. The relevant data requiring pharmacist intervention was defined (e.g., dose adjustments, contraindications, side-effects); a report was devised, based on the patient's electronic medical record; daily follow-up included analysis, stratification, quantification and understanding of the different types of pharmacist interventions. The pharmacist interventions were summed up and assessed for performance and quality control.

RESULTS

Between March 2013 and February 2014 the medical records of 14,499 patients were examined in our hospital Only in 16% of the records an active pharmacist intervention was performed, according to the parameters defined. Interventions for potentially high risk events such as therapeutic duplication, drug administration in spite of contraindication and in spite of documented allergy were very rare, less than 2% of all the pharmacist interventions.

DISCUSSION AND CONCLUSIONS

This joint venture, which is based on an existing platform, reflects an up-to-date view of an important facet of the clinical work performed at the hospital, helps identify trends, potential failures and vulnerabilities with regard to medication treatment and allows the formulation of intervention programs to improve the quality and safety of drug therapy.

Development of clinical pharmacy key performance indicators for hospital pharmacists using a modified Delphi approach

BACKGROUND

Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs).

OBJECTIVE

A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care.

METHODS

A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round.

RESULTS

All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities.

CONCLUSIONS

A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

An evaluation of adherence to society of pharmacists' standards care in pharmacy information systems in Iran

INTRODUCTION

Pharmacy information system (PIS) is a complex computerized system used for collecting, storing, and managing the medication therapy data in the course of patients' care. The purpose of this study was to evaluate the level of adherence to the standards established by the societies of pharmacists in the PISs employed in the hospitals in Isfahan, Iran.

METHODS

The present study was an applied, descriptive-analytical study conducted on the PISs of 19 teaching, private and social insurance hospitals in Isfahan in 2011. Study population consisted of the PISs available in the hospitals under study. Study sample was the same as the study population. The data collection instrument was a self-developed checklist based on the guidelines of the American Society of Health-System Pharmacists and Pharmaceutical Society of Australia, whose validity was assessed and confirmed by expert professors' views. Having been collected by observation and interview methods, data were analyzed by SPSS 18 software using Mann-Whitney statistical test.

RESULTS

The findings of the study revealed that the highest rank in adherence to the standards of societies of pharmacists was obtained by social services hospitals (32.75%), while the private hospitals obtained the lowest rank (23.32%).

CONCLUSIONS

Based on the findings, in the PISs in the hospitals under study, some standards of the society of pharmacists were ignored. Hence, prior to designing and implementing PIS, a needs analysis is required to increase its users' motivation to identify the system potentialities and to allow the system development in compliance with the world technology advancement.

Usefulness of Therapeutic Drug Monitoring of Antiretrovirals in Routine Clinical Practice

BACKGROUND

Clinical trials have shown that therapeutic drug monitoring (TDM) of antiretrovirals (ARV) improves patient care. However, little is known about the usefulness of TDM in routine practice.

METHOD

We reviewed all the trough concentrations of protease inhibitors and nonnucleoside reverse transcriptase inhibitors that were performed for therapeutic failure, suspected drug toxicity, or routine purposes.

RESULTS

Between 1998 and 2001, 146 TDMs were done in 109 HIV patients. Of the 48 patients with therapeutic failure, 62% had resistance to ARV with adequate ARV concentrations, 16% had insufficient drug exposure without any ARV resistance mutations, and 16% combined both resistance and suboptimal drug concentrations. Subsequent therapeutic interventions (increasing adherence and/or changing HAART) resulted in an undetectable viral load in 37.5% of the patients (14/48). Five (24%) of 21 patients with suspected drug toxicity had high drug concentrations associated with side effects. In all the cases, adverse events regressed after reduction of drug dosage. Of the 77 TDMs done for routine purposes, 26% were outside the therapeutic range.

CONCLUSION

The data show that TDM of ARVs in the clinical setting provides important information that can be used to improve the management of HIV patients receiving antiretroviral therapy.

[Need for improvement in education on appropriate prescribing in elderly patients]

Prescribing errors can cause great harm to patients. In the Netherlands, it is estimated that 7000 preventable medication-related hospitals admissions occur annually, caused in many cases by prescribing errors. Elderly patients are at greatest risk, since this patient demographic is most likely to be prescribed multiple medications. Robust education on appropriate prescribing is essential for all clinicians with the authority to prescribe. Currently, some issues still require improvement in the Netherlands: a) education continues to focus heavily on basic pharmacology knowledge instead of patient related pharmacotherapy skills, b) an appropriate assessment procedure on pharmacotherapy knowledge and skills is often lacking, c) there is no mandatory requirement for physicians to maintain their knowledge and skills in the field of pharmacotherapy during their working career. In this article we discuss means to improve this situation, with the overall aim to ensure that all vulnerable elderly patients are in safe hands with each physician.

[Medication review in older people: identification of a new risk group]

The Dutch multidisciplinary guideline on 'Polypharmacy in older people' advises performing an annual medication review for patients aged 65 or older who use five or more drugs and have at least one risk factor for negative outcomes of their drug usage. We describe a 79-year-old male patient with an indication for a medication review and identified drug-related problems (DRPs). Furthermore, we describe two female patients aged 97 and 91 who use fewer than five drugs, dispensed via an automated system, and also have DRPs. We suggest adding the use of a multidose drug-dispensing system as an indication for a medication review. This will also help to identify patients with undertreatment. In addition, we recommend improving collaboration with pharmacists, which may enhance the effect of a medication review by increasing the number of drug changes.

Redesigning the 'choice architecture' of hospital prescription charts: a mixed methods study incorporating in situ simulation testing

OBJECTIVES

To incorporate behavioural insights into the user-centred design of an inpatient prescription chart (Imperial Drug Chart Evaluation and Adoption Study, IDEAS chart) and to determine whether changes in the content and design of prescription charts could influence prescribing behaviour and reduce prescribing errors.

DESIGN

A mixed-methods approach was taken in the development phase of the project; in situ simulation was used to evaluate the effectiveness of the newly developed IDEAS prescription chart.

SETTING

A London teaching hospital.

INTERVENTIONS/METHODS

A multimodal approach comprising (1) an exploratory phase consisting of chart reviews, focus groups and user insight gathering (2) the iterative design of the IDEAS prescription chart and finally (3) testing of final chart with prescribers using in situ simulation.

RESULTS

Substantial variation was seen between existing inpatient prescription charts used across 15 different UK hospitals. Review of 40 completed prescription charts from one hospital demonstrated a number of frequent prescribing errors including illegibility, and difficulty in identifying prescribers. Insights from focus groups and direct observations were translated into the design of IDEAS chart. In situ simulation testing revealed significant improvements in prescribing on the IDEAS chart compared with the prescription chart currently in use in the study hospital. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber's printed name (163/164 vs 0/174; p<0.0001) and contact number (137/164 vs 55/174; p<0.0001). Antiinfective indication (28/28 vs 17/29; p<0.0001) and duration (26/28 vs 15/29; p<0.0001) were more likely to be completed using the IDEAS chart.

CONCLUSIONS

In a simulated context, the IDEAS prescription chart significantly reduced a number of common prescribing errors including dosing errors and illegibility. Positive behavioural change was seen without prior education or support, suggesting that some common prescription writing errors are potentially rectifiable simply through changes in the content and design of prescription charts.