Prevalence and causes of prescribing errors: the PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) study

The Patient-Held Active Record of Medication Status (PHARMS) study: a mixed-methods feasibility analysis

BACKGROUND

Medication errors frequently occur as patients transition between hospital and the community, and may result in patient harm. Novel methods are required to address this issue.

AIM

To assess the feasibility of introducing an electronic patient-held active record of medication status device (PHARMS) at the primary-secondary care interface at the time of hospital discharge.

DESIGN AND SETTING

A mixed-methods study (non-randomised controlled intervention, and a process evaluation of qualitative interviews and non-participant observation) among patients >60 years in an urban hospital and general practices in Cork, Ireland.

METHOD

The number and clinical significance of errors were compared between discharge prescriptions of the intervention (issued with a PHARMS device) and control (usual care, handwritten discharge prescription) groups. Semi-structured interviews were conducted with patients, junior doctors, GPs, and IT professionals, in addition to direct observation of the implementation process.

RESULTS

In all, 102 patients were included in the final analysis (intervention n = 41, control n = 61). Total error number was lower in the intervention group (median 1, interquartile range [IQR] 0-3) than in the control group (median 8, IQR (4-13.5, P<0.001), with the clinical significance score in the intervention group also being lower than the control group (median 2, IQR 0-4 versus median 11, IQR 5-20, P<0.001). The PHARMS device was found to be technically implementable using existing information technology infrastructure, and acceptable to all key stakeholders.

CONCLUSION

The results suggest that using PHARMS devices within existing systems in general practice and hospitals is feasible and acceptable to both patients and doctors, and may reduce medication error.

Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand?

Background

Medication error in developed countries is of primary concern when there is a question of adversity to a patient's health, but in developing countries like India, it is just a term and its significance is undervalued. The incidence of medication error is essential to estimate the proper medical care provided in the healthcare system.

Objective

The main objective of the study is to determine the incidences of medication error in critical care unit and to evaluate its risk outcomes.

Materials and methods

This is a prospective observational study conducted over a period of 6 months in a critical care unit of a tertiary care hospital. Medication chart review method was opted for data collection. The medication errors were mainly classified as prescription, transcription, indenting, dispensing, and administration error. A total of 6,705 charts were reviewed. The NCCMERP risk index was used to evaluate the outcome of errors.

Results

Of the total 6,705 charts, 410 medication errors were found, i.e., 6.11%. The most common error is transcription error that constitutes 44.1% of the total errors, followed by prescription error 40%, and administration error 14%. The frequency of indenting and dispensing errors is negligible with 1.5% and 0.5%, respectively. The main causes of medication errors are due to incomplete prescription 50.2% and wrong doses 22.9%. In drug class, antibiotics and antihypertensive agents are most prone to medication error. About 87.1% errors belonged to the Category B of National Coordinating Council for Medication Error Reporting and Prevention risk index.

Conclusion

Majority of the errors are transcription errors followed by prescription and administration errors. Consultant doctors have to be more vigilant during prescribing and verifying the medication charts. Clinical pharmacists should act as a checkpoint at each step of medication process to identify and prevent medication errors.

How to cite this article

Zirpe KG, Seta B, Gholap S, Aurangabadi K, Gurav SK, Deshmukh AM, et al. Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand? Indian J Crit Care Med 2020;24(9):799–803.

Prescribing errors in electronic prescriptions for outpatients intercepted by pharmacists and the impact of prescribing workload on error rate in a Chinese tertiary-care women and children's hospital

BACKGROUND

Prescribing errors may, influenced by some risk factors, cause adverse drug events. Most studies in this field focus on errors in prescriptions for hospital inpatients, with only a few on those for outpatients. Our study aimed to explore the incidence of prescribing errors in electronic prescriptions and illustrate the trend of prescribing workload and error rate over time.

METHODS

The cross-section study was performed between September, 2015 and November, 2015. Prescribing errors were intercepted by pharmacists using a prescription reviewing system under which prescriptions with errors were transferred to a specific computer and recorded by another pharmacist and the incidence of total prescribing errors and severe errors was then calculated. A subgroup analysis was conducted in accordance to the number of drug orders, the age group of patients, the seniority of physicians, the specialty of physicians, the working day when prescriptions were issued, and the prescribing workload of physicians. A time-series analysis was employed to analyze the trend of prescribing workload and error rate, and the correlation between them.

RESULTS

Totally, 65,407 patients were included in this study and 150,611 prescriptions with 294,564 drug orders (including 584 different drugs) were reviewed for identification of errors. A total of 534 prescribing errors (an error rate of 0.34%) were identified. Severe errors accounted for 13.62% of total errors. The subgroup analysis showed prescriptions of multiple drug orders, for pediatric patients aged 29 days to 12 years, from physicians specializing in ophthalmology and otorhinolaryngology, or prescribing on weekdays were more susceptible to errors. A time-series analysis demonstrated no correlation between prescribing workload and error rate which increased at the end of each working shift while prescribing workload decreased.

CONCLUSION

Less than 1% of the studied prescriptions came with errors among which one in seven were severe ones. But prescribing errors were in no relation to workloads. What's more, further studies are needed to investigate pharmacist-led intervention to reduce prescribing errors.

Microbiology of Cystic Fibrosis Airway Disease

Although survival of individuals with cystic fibrosis (CF) has been continuously improving for the past 40 years, respiratory failure secondary to recurrent pulmonary infections remains the leading cause of mortality in this patient population. Certain pathogens such as Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and species of the Burkholderia cepacia complex continue to be associated with poorer clinical outcomes including accelerated lung function decline and increased mortality. In addition, other organisms such as anaerobes, viruses, and fungi are increasingly recognized as potential contributors to disease progression. Culture-independent molecular methods are also being used for diagnostic purposes and to examine the interaction of microorganisms in the CF airway. Given the importance of CF airway infections, ongoing initiatives to promote understanding of the epidemiology, clinical course, and treatment options for these infections are needed.

"It's helpful to get the time and opportunity to discuss drug treatment; that's what I think is the most important thing."-A qualitative study on prescribing education in junior physicians

BACKGROUND

As prescribing skills are a prerequisite for rational use of medicines, and education and training are important in acquiring these skills, we aimed to explore what aspects junior physicians find important when being taught the art of prescribing.

METHODS

Written feedback from 34 interns after participating in an educational session as part of a randomized controlled study at a university hospital formed the qualitative data in this study. Manifest content analysis was performed, guided by the research question "Educating junior physicians in the art of prescribing: what aspects do they find important?" Meaning units were extracted and categorized, and emergent themes were identified.

RESULTS

Five themes emerged. The first, clinical relevance, was exemplified by the categories valuable for health care; perceived relevance for one's own work; and translating theory into practice while the second, applicable content, included categories such as clinical advice; practical tips on using the electronic medical record system; and tools that facilitate. The third and fourth themes, reality-based teaching and creative discussions, were exemplified by the categories patient cases and feedback; and discussion-based teaching; wide-ranging discussions and a permissive and open atmosphere, respectively. In the last theme, effective structure, we identified the categories clear structure; small group teaching; allocated time for discussion; well-organized administration; and home assignment for practice.

CONCLUSION

Creative discussions, effectively structured in small group sessions, with clinically relevant, reality-based content built on case studies and feedback, are aspects which junior physicians find important when educated in the art of prescribing.

What causes prescribing errors in children? Scoping review

OBJECTIVES

(1) Systematically assemble, analyse and synthesise published evidence on causes of prescribing error in children. (2) Present results to a multidisciplinary group of paediatric prescribing stakeholders to validate findings and establish how causative factors lead to errors in practice.

DESIGN

Scoping review using Arksey and O'Malley's framework, including stakeholder consultation; qualitative evidence synthesis.

METHODS

We followed the six scoping review stages. (1) Research question-the research question was 'What is known about causes of prescribing error in children?' (2) Search strategy-we searched MEDLINE, EMBASE, CINAHL (from inception to February 2018), grey literature and reference lists of included studies. (3) Article selection-all published evidence contributing information on the causes of prescribing error in children was eligible for inclusion. We included review articles as secondary evidence to broaden understanding. (4) Charting data-results were collated in a custom data charting form. (5) Reporting results-we summarised article characteristics, extracted causal evidence and thematically synthesised findings. (6) Stakeholder consultation-results were presented to a multidisciplinary focus group of six prescribing stakeholders to establish validity, relevance and mechanisms by which causes lead to errors in practice.

RESULTS

68 articles were included. We identified six main causes of prescribing errors: children's fundamental differences led to individualised dosing and calculations; off-licence prescribing; medication formulations; communication with children; and experience working with children. Primary evidence clarifying causes was lacking.

CONCLUSIONS

Specific factors complicate prescribing for children and increase risk of errors. Primary research is needed to confirm and elaborate these causes of error. In the meantime, this review uses existing evidence to make provisional paediatric-specific recommendations for policy, practice and education.

The role of undergraduate teaching, learning and a national prescribing safety assessment in preparation for practical prescribing: UK medical students' perspective

AIMS

To investigate medical students' perspectives on the influence of their undergraduate course and the UK prescribing safety assessment (PSA) on the acquisition of practical prescribing skills.

METHODS

An online questionnaire comprising multiple choice and open-ended questions was available to UK medical students in years 3, 4 and 5. Descriptive statistics and thematic analysis were completed.

RESULTS

In total, 1023 medical students from 25 UK medical schools responded: 22% (3rd year), 37% (4th year) and 41% (final year). A minority of medical students believed that their medical course prepared them sufficiently for practical prescribing (36.4%, n = 372, 95% confidence interval [CI] = 32-41%), 52.6%, of students thought that practical prescribing should be introduced into the curriculum earlier (n = 538, CI = 48-57%), and 73.7% reported that a more consistent approach to the teaching and learning of practical prescribing might be beneficial (n = 754, CI = 71-77%). An awareness of the national PSA was high (86.5%, n = 885), particularly amongst final year students (98.3%, n = 413, CI = 97-100%); 67.4% of all students (n = 690, CI = 64-71%) and 72.1% (n = 303) of final year students perceived that the PSA will improve or had improved their practical prescribing skills.

CONCLUSIONS

The majority of medical students perceive that their undergraduate course does not adequately prepare them for practical prescribing. Many believe that there is some merit in introducing practical prescribing teaching earlier in the curriculum and medical schools adopting a more consistent approach. Among medical students, the PSA is thought to have a positive influence on prescribing skills learning. These data might be useful in developing a programme of study dedicated to practical prescribing.

Using prescribing very short answer questions to identify sources of medication errors: a prospective study in two UK medical schools

OBJECTIVE

To assess the utility and ability of the novel prescribing very short answer (VSA) question format to identify the sources of undergraduate prescribing errors when compared with the conventional single best answer (SBA) question format and assess the acceptability of machine marking prescribing VSAs.

DESIGN

A prospective study involving analysis of data generated from a pilot two-part prescribing assessment.

SETTING

Two UK medical schools.

PARTICIPANTS

364 final year medical students took part. Participation was voluntary. There were no other inclusion or exclusion criteria.

OUTCOMES

(1) Time taken to mark and verify VSA questions (acceptability), (2) differences between VSA and SBA scores, (3) performance in VSA and (4) SBA format across different subject areas and types of prescribing error made in the VSA format.

RESULTS

18 200 prescribing VSA questions were marked and verified in 91 min. The median percentage score for the VSA test was significantly lower than the SBA test (28% vs 64%, p<0.0001). Significantly more prescribing errors were detected in the VSA format than the SBA format across all domains, notably in prescribing insulin (96.4% vs 50.3%, p<0.0001), fluids (95.6% vs 55%, p<0.0001) and analgesia (85.7% vs 51%, p<0.0001). Of the incorrect VSA responses, 33.1% were due to the medication prescribed, 6.0% due to the dose, 1.4% due to the route and 4.8% due to the frequency.

CONCLUSIONS

Prescribing VSA questions represent an efficient tool for providing detailed insight into the sources of significant prescribing errors, which are not identified by SBA questions. This makes the prescribing VSA a valuable formative assessment tool to enhance students' skills in safe prescribing and to potentially reduce prescribing errors.

The MOWER (middle of the week everyone gets a re-chart) pilot study: reducing in-hospital charting error with a multi-intervention

Background

Medication charting errors occur often and can be harmful for patients. Interventions to improve charting errors have demonstrated some success particularly if the intervention uses multiple approaches including an education component. The aim of this pilot study was to determine whether a multi-faceted intervention, including education of junior doctors and weekday re-charting could reduce in-hospital charting error.

Methods

Medication charts (n = 579) of all patients admitted to the medical ward of a medium sized regionally-based hospital in Australia over nine months (baseline and during intervention) were inspected for errors. The intervention ran for three months and involved implementation of a National Inpatient Medication Chart targeted error tool with eight targeted charting requirements which was used for visual reminders in the ward and training of junior doctors. In addition, mid-weekly re-charting (MOWER) was performed by a senior and junior doctor team.

Results

The mean number of charting requirement errors significantly reduced during the intervention by 26% from 4.6 ± 1.3 to 3.4 ± 1.7 per chart (p < 0.001). Re-chart errors reduced on average by 50% (4.4 ± 1.4 to 2.2 ± 1.7 per chart, p < 0.001) and primary (initial) charts by 20% (4.6 ± 1.3 to 3.7 ± 1.5 per chart, p < 0.001) during the intervention. Failing to provide indication information for a drug, prescriber name, and failing to use generic rather than brand names were the categories with the most errors at baseline and also showed the largest error reductions during the intervention.

Conclusions

A multi-intervention including education of junior doctors, visual reminders and midweek re-charting are effective in reducing the rate of charting errors. We advise that a larger study is now conducted using the same multi-intervention strategy in different ward settings to evaluate feasibility and sustainability of this intervention.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4230-y) contains supplementary material, which is available to authorized users.

Towards a "prescribing license" for medical students: development and quality evaluation of an assessment for safe prescribing

PURPOSE

This report describes the development and validation process of an assessment with national consensus in appropriate and safe pharmacotherapy.

METHODS

A question-database on safe prescription based on literature of pharmacotherapy-related harm was developed by an expert group from Dutch medical faculties. Final-year medical students concluded a 2-year education program on appropriate and safe prescription by one of nine assessment variants of 40 multiple-choice questions each. An expert panel of professionals (n = 10) answered all database questions and rated questions on relevance. Questions were selected for revision based on lack of relevance or poor test and item characteristics.

RESULTS

A total of 576 final-year medical students of the Radboud University was assessed. There was no significant difference in performance between students and content expert group (p = 0.7), probably due to learning behavior. Out of 165 questions, 59 were selected for revision.

CONCLUSION

Joint national effort from a team of experts in prescription and pharmacotherapy is an appropriate way to achieve a valid and reliable last-year student drug prescription assessment.

Comparison of emergency physiotherapy practitioner prescribers versus existing emergency department prescribers for musculoskeletal injuries

OBJECTIVE

The scope of selected emergency physiotherapy practitioners (EPP) in this Australian non-tertiary ED has recently extended to include the prescription of a limited drug formulary, including paracetamol, some NSAIDs and opioids, an anti-emetic, a benzodiazepine and nitrous oxide. Although there are large-scale studies investigating prescription errors made by doctors, there is a lack of data on prescribing practices of physiotherapists in the ED setting. The aim of present study is to compare the prescribing practices of EPP to their medical and nursing colleagues within the setting of treating musculoskeletal injuries in the ED.

METHODS

One hundred retrospective National Inpatient Medication Chart (NIMC) audits of adult patients presenting primarily with musculoskeletal complaints were undertaken using the standardised NIMC audit tool, with patient demographics, and NIMC audit results compared between groups.

RESULTS

Fifty medication charts were audited for each group, with a total of 212 drug orders. EPP demonstrated higher completion rates for patient identification, patient weight and medication history compared to medical and nursing staff. Legibility of drug names and route of administration appeared equivalent, whereas EPP had higher completion rates for legible drug doses and signatures compared to medical and nursing staff.

CONCLUSION

In the management of ED patients with musculoskeletal complaints, prescription-trained EPP appear to perform similarly if not better than their medical and nursing colleagues with regards to NIMC audit tool results.

What is the impact of introducing inpatient electronic prescribing on prescribing errors? A naturalistic stepped wedge study in an English teaching hospital

Most studies evaluating the impact of electronic prescribing on prescribing safety have used comparatively weak study designs such as uncontrolled before-and-after studies. This study aimed to apply a more robust naturalistic stepped wedge study design to compare the prevalence and types of prescribing errors for electronic prescribing and paper prescribing. Data were collected weekly during a phased electronic prescribing implementation across 20 wards in a large English hospital. We identified 511 (7.8%) erroneous orders in 6523 paper medication orders, and 312 (6.0%) in 5237 electronic prescribing orders. Logistic regression suggested no statistically significant effect of electronic prescribing use or of study week; patient and ward had significant effects. Errors involving incorrect doses and illegible or incomplete orders were less common with electronic prescribing; those involving duplication, omission, incorrect drug and incorrect formulation were more common. Actions are needed to mitigate these error types; future studies should give more consideration to the effects of patient and ward.

"Hopefully, I will never forget that again" - sensitizing medical students for drug safety by working on cases and simulating doctor-patient communication

Objective: This project is part of the "PJ-STArT-Block", a one-week course preparing 10^th semester medical students for their final practical year. The focus is on sensitizing students to aspects of medication safety by becoming aware of their skills and their deficits in terms of application and communication of pharmacological knowledge. The modules were evaluated regarding feasibility, acceptance and possible effects. Furthermore, the areas in which students see their pharmacological deficits or learning successes were gathered. Methods: In simulated physician-patient conversations, the students are to identify drug-related problems such as medication errors, adverse drug events or interactions. Together with their fellow students and under medical or pharmaceutical moderation, they then have to find solutions for the identified problems and communicate these solutions to the patients. Based on paper cases, students practice, reflect, and discuss the research of reliable information about drugs and medication therapy. The written evaluation included the evaluation by school grades and the possibility of comments in free text. A content analysis of interviews with students at the beginning of the project aimed to identify areas of pharmacology in which they see their own deficits. Results: Evaluation results including the free text comments indicate students' acceptance of our pharmacology modules. According to this, the students realize the importance of aspects relevant for medication safety. The areas mentioned in 35 interviews in which students localize deficits, correspond to the topics that were intended when conceiving the modules and which are important for medication safety (e.g. interactions, adverse drug effects, dosages). Conclusion: Implementation of context-based, application-oriented teaching formats as recently claimed for pharmacological education to improve the quality of prescriptions, is possible, as the Cologne example shows. The student evaluation turns out positively and indicates a critical self-reflection. The students identified various pharmacological deficits in themselves, which have since been confirmed and quantified in another study.

Foundation year one and year two doctors' prescribing errors: a comparison of their causes

OBJECTIVE

Junior doctors have the highest rates of prescribing errors, yet no study has set out to understand the differences between completely novice prescribers (Foundation year one (FY1) doctors) and those who have gained some experience (Foundation year two (FY2) doctors). The objective of this study was to uncover the causes of prescribing errors made by FY2 doctors and compare them with previously collected data of the causes of errors made by FY1 doctors.

DESIGN

Qualitative interviews, using the critical incident technique, conducted with 19 FY2 doctors on the causes of their prescribing errors and compared with interviews previously conducted with 30 FY1 doctors. Data were analysed using a constant comparison approach after categorisation of the data using Reason's model of accident causation and the London protocol.

RESULTS

Common contributory factors in both FY1 and FY2 doctors' prescribing errors included working on call, tiredness and complex patients. Yet, important differences were revealed in terms of application of prescribing knowledge, with FY1 doctors lacking knowledge and FY2 misplacing their knowledge. Due to the rotation of foundation doctors, both groups are faced with novel prescribing contexts, yet the previous experience that FY2 doctors gained led to misplaced confidence when caution would have been expedient.

CONCLUSIONS

Differences in the contributory factors of prescribing errors should be taken into account when designing interventions to improve the prescribing of foundation doctors. Furthermore, careful consideration should be taken when inferring expertise in FY2 doctors, who are likely to prescribe in contexts in which their experience is little different to an FY1 doctor.

Prescribing errors by junior doctors- A comparison of errors with high risk medicines and non-high risk medicines

INTRODUCTION

Prescribing errors in hospital are common. However, errors with high-risk-medicines (HRMs) have a greater propensity to cause harm compared to non-HRMs. We do not know if there are differences between the causes of errors with HRMs and non-HRMs but such knowledge might be useful in developing interventions to reduce errors and avoidable harm. Therefore, this study aims to compare and contrast junior doctors' prescribing errors with HRMs to non-HRMs to establish any differences.

METHODS

A secondary analysis of fifty-nine interviews with foundation year doctors, obtained from three studies, was conducted. Using a Framework Analysis approach, through NVivo software, a detailed comparison was conducted between the unsafe acts, error-causing-conditions (ECCs), latent conditions, and types of errors related to prescribing errors with HRMs and non-HRMs.

RESULTS

In relation to unsafe acts, violations were described in the data with non-HRMs only. Differences in ECCs of HRMs and non-HRMs were identified and related to the complexity of prescribing HRMs, especially dosage calculations. There were also differences in the circumstances of communication failures: with HRMs ineffective communication arose with exchanges with individuals outside the immediate medical team while with non-HRMs these failures occurred with exchanges within that team. Differences were identified with the latent conditions: with non-HRMs there was a reluctance to seek seniors help and with HRMs latent conditions related to the organisational system such as the inclusion of trade names in hospital formularies. Moreover, prescribing during the on-call period was particularly challenging especially with HRMs.

CONCLUSION

From this secondary analysis, differences in the nature and type of prescribing errors with HRMs and non-HRMs were identified, although further research is needed to investigate their prevalence. As errors with HRMs have the potential to cause great harm it may be appropriate to target limited resources towards interventions that tackle the underlying causes of such errors. Equally concerning, however, was the sense that doctors regard the prescribing of non-HRMs as 'safe'.

Pharmacist interventions in high-risk obstetric inpatient unit: a medication safety issue

Objectives

The aim of this study was to report number, type and severity of prescribing errors and pharmacist interventions in high-risk pregnant and postpartum women.

Design

A prospective cross-sectional, observational study.

Setting

A high-risk obstetric inpatient unit of a Women's Hospital in Brazil.

Participants

About 1826 electronic prescriptions for 549 women in the high-risk obstetrics inpatient unit were included.

Interventions

When the pharmacist detected potential prescribing errors, interventions were suggested.

Main Outcome Measures

Prescriptions were evaluated by clinical pharmacist to identify the type, frequency and severity of prescribing errors and rate of clinical pharmacist intervention acceptance in a high-risk obstetric inpatient.

Results

A total of 1826 prescriptions were reviewed with 128 errors (7.0%). The most frequent errors were drug interaction (43.8%), incorrect frequency (21.5%) and improper dose (13.1%). One-hundred and sixty-eight interventions were made by pharmacists, 98.8% of which were accepted by prescribers. Higher maternal age (OR 1.0 (95%CI 1.0-1.1)), higher number of prescribed medications (OR 1.2 (95%CI 1.1-1.3)), obstetric conditions (OR 2.2 (95%CI 1.4-3.3)) and non-breastfeeding postpartum women (OR 3.9 (95% CI 2.5-6.1)) were the independent factors associated with prescribing errors identified through multivariate analysis.

Conclusions

The most common prescription errors related to drug interactions, incorrect frequency and higher number of prescribed medications. The rate of pharmacist acceptance intervention was high.

Relationship between acute stress and clinical performance in medical students: a pilot simulation study

Background

Acute stress has been linked to impaired clinical performance in healthcare settings. However, few studies have measured experienced stress and performance simultaneously using robust measures in controlled experimental conditions, which limits the strength of their findings.

Aim

In the current study we examined the relationship between acute stress and clinical performance in second-year medical students undertaking a simulated ECG scenario. To explore this relationship in greater depth we manipulated two variables (clinical urgency and cognitive load), and also examined the impact of trait anxiety and task self-efficacy.

Methods

Second-year medical students were asked to conduct a 12-lead ECG on a simulated patient. Students were randomly assigned to one of four experimental conditions according to clinical urgency (high/low) and cognitive load (high/low), which were manipulated during a handover prior to the ECG. As part of the scenario they were asked to describe the ECG trace to a senior doctor over the phone and to conduct a drug calculation. They then received a performance debrief. Psychological stress and physiological stress were captured (via self-report and heart rate, respectively) and various aspects of performance were observed, including technical competence, quality of communication, work rate and compliance with patient safety checks. Trait anxiety and task self-efficacy were also captured via self-report.

Results

Fifty students participated. While there was little impact of experimental condition on stress or performance, there was a significant relationship between stress and performance for the group as a whole. Technical competence was poorer for those reporting higher levels of psychological stress prior to and following the procedure. Neither trait anxiety nor task self-efficacy mediated this relationship.

Conclusions

This study has provided evidence for a link between acute stress and impaired technical performance in medical students completing a simulated clinical scenario using real-time measures. The implications for patient safety and medical education are discussed.

Development of perceived pharmacological deficits of medical students and alumni supports claim for continuous and more application-oriented education

Medical students' prescribing competencies are insufficient. So far, surveys focused on final-year students. Knowledge and confidence seem important, but their development during medical studies are unclear. This study investigated whether students perceived deficits in pharmacological knowledge change during medical studies. Alumni were included to look for changes occurring after graduation. Medical students at different stages of their studies were invited to fill in paper-and-pencil (6th-, 8th-, 9th- and 10th-term students) or online questionnaires (final-year students and alumni) regarding their self-assessed deficits in pharmacology. Questionnaires have been developed based on previous interviews with 10th-term students. We differentiated between declarative and application-oriented knowledge. In total, data from 816 participants could be analysed. Self-assessment regarding declarative knowledge changed during medical studies, being more sceptical in terms without pharmacology courses. Of note, self-assessment of application-oriented knowledge remained constantly low throughout, although our pharmacology courses use problem-based learning. Tenth-term students were most sceptical, perhaps influenced by an obligatory, formative, simulation-based, 1-week course, preparing students for their final practical year. Compared to students, alumni were significantly less sceptical regarding application-oriented knowledge. Students' self-assessment of deficits in pharmacological knowledge changes throughout their studies, presumably in association with pharmacology courses. Overall, students are rather sceptical, especially with regard to application-oriented knowledge. Our data further substantiate the European Association for Clinical Pharmacology and Therapeutics (EACPT) recommendations to improve pharmacology education throughout the entire medical curriculum, e.g. by providing more training in simulated and clinical environments.

Essential diseases in prescribing: A national Delphi study towards a core curriculum in pharmacotherapy education

AIMS

Prescribing is a core skill for junior doctors, yet 8-10% of their prescriptions contain errors. To ensure adequate training in prescribing, it is important to define the diseases for which junior doctors should be competent to prescribe. The aim of the present study was therefore to identify the essential diseases in prescribing for junior doctors.

METHODS

A two-round Delphi consensus study was conducted among medical specialists, general practitioners, junior doctors, pharmacists and pharmacotherapy teachers from all eight academic hospitals in the Netherlands. Using a five-point Likert scale, the participants indicated for each item on an initial questionnaire whether it should be considered an essential disease for junior doctors. The items for which ≥80% of all respondents agreed or strongly agreed were accepted as essential diseases.

RESULTS

Sixty-two participants completed the Delphi survey. In total, 63 of 220 items were considered to be essential diseases.

CONCLUSION

This is the first Delphi consensus study identifying exact conditions that junior doctors must be able to prescribe for. The essential diseases can be used for training in prescribing and assessment of junior doctors' prescribing competence.

Prevalence of prescription errors in general practice in Jeddah, Saudi Arabia

PURPOSE

Prescription errors are a common cause of adverse drug events (ADEs). Recognizing ADEs can significantly contribute to the reduction of morbidity and mortality. This study aims to investigate the type and prevalence of errors in prescription writing, directed toward a needs assessment for developing educational interventions.

MATERIALS AND METHODS

A cross-sectional descriptive study was conducted in Jeddah community pharmacies (January-February 2016). A random sample of 117 prescriptions were reviewed and analyzed by community pharmacists for legibility and omission of the information in the prescription.

RESULTS

Results revealed that 51% of the prescriptions included diagnosis, in which 62% included the recommended drug dosage. Only 7% of drug interactions were reported between the prescribed drugs, 17% of the physicians prescribed drugs that prevented the adverse effects used for diagnosis. Prescriptions for chronic conditions were scrutinized to be 18%. It was noteworthy that 29% of the pharmacists reported difficulty in reading the handwriting of prescriptions.

CONCLUSIONS

The quality of prescription writing is deficient in some elements and strategies for improvement are needed. These findings underscore a crucial requirement to upgrade the quality of prescription writing by encouraging continuous medical education programs to facilitate delivery of excellent therapeutic outcomes.

Exploring the utility of the Prescribing Safety Assessment in pharmacy education in England: experiences of pre-registration trainees and undergraduate (MPharm) pharmacy students

OBJECTIVES

(i) To provide a preliminary indication of the performance of pharmacy undergraduate students and pre-registration pharmacy trainees in the Prescribing Safety Assessment (PSA). (ii) To determine the feasibility of administering and delivering the PSA in schools of pharmacy. (iii) To examine the potential relevance of the PSA and associated training materials to pharmacy education. (iv) To assess the attitudes of the cohort towards the PSA and their readiness to prescribe.

METHODS

Four schools of pharmacy in England recruited final year undergraduate pharmacy students and pre-registration pharmacy trainees undertaking training with both hospital and community pharmacy employers in their locality to undertake the PSA. Performance data and feedback from candidates were obtained.

KEY FINDINGS

Pre-registration pharmacy trainees in community (n = 27) and hospital (n = 209) settings mean average scores were 86.3% and 85.3%, respectively. There was a significant performance differential between undergraduate pharmacy students (n = 397) and those in pre-registration training, with the mean average score for undergraduate students being 73.0% (t test P < 0.05). Candidates felt their current course did prepare them for the PSA, some highlighted that additional curriculum content would be needed should this become a compulsory high-stakes assessment for pharmacy trainees. The majority of candidates felt that this assessment was useful and applicable to their training.

CONCLUSIONS

The PSA process and associated learning tools could be introduced to pre-registration pharmacy education to support trainees in their development towards future prescribing roles.

The role of the smartphone in the transition from medical student to foundation trainee: a qualitative interview and focus group study

BACKGROUND

The transition from medical student to junior doctor is one of the most challenging in medicine, affecting both doctor and patient health. Opportunities to support this transition have arisen from advances in mobile technology and increased smartphone ownership.

METHODS

This qualitative study consisted of six in-depth interviews and two focus groups with Foundation Year 1 Trainees (intern doctors) and final year medical students within the same NHS Trust. A convenience sample of 14 participants was recruited using chain sampling. Interviews and focus groups were recorded, transcribed verbatim, analysed in accordance with thematic analysis and presented below in keeping with the standards for reporting qualitative research.

RESULTS

Participants represented both high and low intensity users. They used their smartphones to support their prescribing practices, especially antimicrobials through the MicroGuide™ app. Instant messaging, via WhatsApp, contributed to the existing bleep system, allowing coordination of both work and learning opportunities across place and time. Clinical photographs were recognised as being against regulations but there had still been occasions of use despite this. Concerns about public and colleague perceptions were important to both students and doctors, with participants describing various tactics employed to successfully integrate phone use into their practices.

CONCLUSION

This study suggests that both final year medical students and foundation trainees use smartphones in everyday practice. Medical schools and healthcare institutions should seek to integrate such use into core curricula/training to enable safe and effective use and further ease the transition to foundation training. We recommend juniors are reminded of the potential risks to patient confidentiality associated with smartphone use.

The role of the pharmacist in the intensive care unit

The use of medication to support patients and optimise outcomes is a fundamental strand of care. Pharmacists provide a key role managing medication within the complexity of various routes of administration, severe and rapidly shifting pharmacokinetic and dynamic parameters, and extremes of physiology in critical illness. Pharmacists intercept and resolve medication errors, optimise medication therapy and undertake broader professional activities within the job role that contribute to the smooth running of ICU. These activities are associated with improved quality, reduced mortality and reduced costs.

Pharmacist prescribing in critical care: an evaluation of the introduction of pharmacist prescribing in a single large UK teaching hospital

OBJECTIVES

To evaluate the introduction of pharmacist independent prescribing activity across three general critical care units within a single large UK teaching hospital. To identify the prescribing demographics including total of all prescriptions, number prescribed by pharmacists, reason for pharmacist prescription, range of medications prescribed, pharmacist prescribing error rate and the extent of pharmacist second 'clinical check'.

METHODS

Retrospective evaluation of e-prescribing across all general critical care units of a single large UK teaching hospital. All prescribing data were downloaded over a 1-month period (May to June 2016) with analysis of pharmacist prescribing activity including rate, indication, therapeutic class and error rate.

RESULTS

In total, 5374 medicines were prescribed in 193 patients during the evaluated period. Prescribing pharmacists were available on the units on 60.4% (58/96) of days, during their working hours and accounted for 576/5374 (10.7%) of medicines prescribed in 65.2% (126/193) of patients. The majority (342/576) of pharmacist prescriptions were for new medicines. Infections, central nervous system, and nutrition/blood were the top three British National Formulary (BNF) therapeutic categories, accounting for 63.4% (349/576) of all pharmacist prescriptions. The critical care pharmacist prescribing error rate was 0.18% (1/550).

CONCLUSIONS

Pharmacist independent prescribers demonstrated a high degree and wide-ranging scope of prescribing activity in general critical care patients. Pharmacists contributed a significant proportion of total prescribing, despite less than full service coverage. Prescribing activity was also safe with a very low error rate recorded.

Competency-based learning in an ambulatory care setting: Implementation of simulation training in the Ambulatory Care Rotation during the final year of the MaReCuM model curriculum

Aim: As part of the MaReCuM model curriculum at Medical Faculty Mannheim Heidelberg University, a final year rotation in ambulatory care was implemented and augmented to include ambulatory care simulation. In this paper we describe this ambulatory care simulation, the designated competency-based learning objectives, and evaluate the educational effect of the ambulatory care simulation training. Method: Seventy-five final year medical students participated in the survey (response rate: 83%). The control group completed the ambulatory rotation prior to the implementation of the ambulatory care simulation. The experimental group was required to participate in the simulation at the beginning of the final year rotation in ambulatory care. A survey of both groups was conducted at the beginning and at the end of the rotation. The learning objectives were taken from the National Competency-based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM). Results: The ambulatory care simulation had no measurable influence on students' subjectively perceived learning progress, the evaluation of the ambulatory care rotation, or working in an ambulatory care setting. At the end of the rotation participants in both groups reported having gained better insight into treating outpatients. At the beginning of the rotation members of both groups assessed their competencies to be at the same level. The simulated ambulatory scenarios were evaluated by the participating students as being well structured and easy to understand. The scenarios successfully created a sense of time pressure for those confronted with them. The ability to correctly fill out a narcotic prescription form as required was rated significantly higher by those who participated in the simulation. Participation in the ambulatory care simulation had no effect on the other competencies covered by the survey. Discussion: The effect of the four instructional units comprising the ambulatory care simulation was not measurable due to the current form or the measurement point at the end of the 12-week rotation. The reasons for this could be the many and statistically elusive factors relevant to the individual and the wide variety among final year rotation placements, the late point in time of the final survey, and the selection of simulated scenarios. The course is slated to undergo specific further development and should be supplemented with additional learning opportunities to ensure that the main learning objectives are covered. The description of the teaching format is meant to contribute to the ongoing development of medical education with an emphasis on competency in the areas of ambulatory care, communication, prevention and health promotion.

Do final-year medical students have sufficient prescribing competencies? A systematic literature review

Aims

Prescribing errors are an important cause of patient safety incidents and are frequently caused by junior doctors. This might be because the prescribing competence of final‐year medical students is poor as a result of inadequate clinical pharmacology and therapeutic (CPT) education. We reviewed the literature to investigate which prescribing competencies medical students should have acquired in order to prescribe safely and effectively, and whether these have been attained by the time they graduate.

Methods

PubMed, EMBASE and ERIC databases were searched from the earliest dates up to and including January 2017, using the terms ‘prescribing’, ‘competence’ and ‘medical students’ in combination. Articles describing or evaluating essential prescribing competencies of final‐year medical students were included.

Results

Twenty‐five articles describing, and 47 articles evaluating, the prescribing competencies of final‐year students were included. Although there seems to be some agreement, we found no clear consensus among CPT teachers on which prescribing competencies medical students should have when they graduate. Studies showed that students had a general lack of preparedness, self‐confidence, knowledge and skills, specifically regarding general and antimicrobial prescribing and pharmacovigilance. However, the results should be interpreted with caution, given the heterogeneity and methodological weaknesses of the included studies.

Conclusions

There is considerable evidence that final‐year students have insufficient competencies to prescribe safely and effectively, although there is a need for a greater consensus among CPT teachers on the required competencies. Changes in undergraduate CPT education are urgently required in order to improve the prescribing of future doctors.

Can a two-hour lecture by a pharmacist improve the quality of prescriptions in a pediatric hospital? A retrospective cohort study

BACKGROUND

A high rate of prescription errors exists in pediatric teaching hospitals, especially during initial training.

OBJECTIVES

To determine the effectiveness of a two-hour lecture by a pharmacist on rates of prescription errors and quality of prescriptions.

METHODS

A two-hour lecture led by a pharmacist was provided to 11 junior pediatric residents (PGY-1) as part of a one-month immersion program. A control group included 15 residents without the intervention. We reviewed charts to analyze the first 50 prescriptions of each resident.

RESULTS

Data were collected from 1300 prescriptions involving 451 patients, 550 in the intervention group and 750 in the control group. The rate of prescription errors in the intervention group was 9.6% compared to 11.3% in the control group (p=0.32), affecting 106 patients. Statistically significant differences between both groups were prescriptions with unwritten doses (p=0.01) and errors involving overdosing (p=0.04). We identified many errors as well as issues surrounding quality of prescriptions.

CONCLUSION

We found a 10.6% prescription error rate. This two-hour lecture seems insufficient to reduce prescription errors among junior pediatric residents. This study highlights the most frequent types of errors and prescription quality issues that should be targeted by future educational interventions.

Reliability of clinical impact grading by healthcare professionals of common prescribing error and optimisation cases in critical care patients

Objective

To identify between and within profession-rater reliability of clinical impact grading for common critical care prescribing error and optimisation cases. To identify representative clinical impact grades for each individual case.

Design

Electronic questionnaire.

Setting

5 UK NHS Trusts.

Participants

30 Critical care healthcare professionals (doctors, pharmacists and nurses).

Intervention

Participants graded severity of clinical impact (5-point categorical scale) of 50 error and 55 optimisation cases.

Main Outcome Measures

Case between and within profession-rater reliability and modal clinical impact grading.

Methods

Between and within profession rater reliability analysis used linear mixed model and intraclass correlation, respectively.

Results

The majority of error and optimisation cases (both 76%) had a modal clinical severity grade of moderate or higher. Error cases: doctors graded clinical impact significantly lower than pharmacists (-0.25; P < 0.001) and nurses (-0.53; P < 0.001), with nurses significantly higher than pharmacists (0.28; P < 0.001). Optimisation cases: doctors graded clinical impact significantly lower than nurses and pharmacists (-0.39 and -0.5; P < 0.001, respectively). Within profession reliability grading was excellent for pharmacists (0.88 and 0.89; P < 0.001) and doctors (0.79 and 0.83; P < 0.001) but only fair to good for nurses (0.43 and 0.74; P < 0.001), for optimisation and error cases, respectively.

Conclusions

Representative clinical impact grades for over 100 common prescribing error and optimisation cases are reported for potential clinical practice and research application. The between professional variability highlights the importance of multidisciplinary perspectives in assessment of medication error and optimisation cases in clinical practice and research.

Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation in an English hospital

BACKGROUND

Few studies have applied a systems approach to understanding the causes of specific prescribing errors in the context of hospital electronic prescribing (EP). A comprehensive understanding of underlying causes is essential for developing effective interventions to improve prescribing safety. Our objectives were to explore prescribers' perspectives of the causes of errors occurring with EP and to make recommendations to maximise benefits and minimise risks.

METHODS

We studied a large hospital using inpatient EP. From April to June 2016, semistructured interviews were conducted with purposively sampled prescribers involved with a prescribing error. Interviews explored prescribers' perceived causes of the error and views about EP; they were audio-recorded and transcribed verbatim. Data were thematically analysed against a framework based on Reason's accident causation model, with a focus on identifying latent conditions.

RESULTS

Twenty-five interviews explored causes of 32 errors. Slips and rule-based mistakes were the most common active failures. Error causation was multifactorial; environmental, individual, team, task and technology error-producing conditions were all influenced by EP. There were three broad groups of latent conditions: the EP system's functionality and design; the organisation's decisions around EP implementation and use; and prescribing behaviours in the context of EP.

CONCLUSIONS

Errors were associated with the design of EP itself and its integration within the healthcare environment. Findings suggest that EP vendors should focus on revolutionising interface design and usability issues, bearing in mind the wider healthcare context in which such software is used. Healthcare organisations should draw upon human factors principles when implementing EP. Consideration of work environment, infrastructure, training, prescribing responsibilities and behaviours should be considered to address local issues identified.

Assessing the association between thinking dispositions and clinical error

BACKGROUND

Dual-process theory suggests that type 1 thinking results in a propensity to make 'intuitive' decisions based on limited information. Type 2 processes, on the other hand, are able to analyse these initial responses and replace them with rationalised decisions. Individuals may have a preference for different modes of rationalisation, on a continuum from careful to cursory. These 'dispositions' of thinking reside in type 2 processes and may result in error when the preference is for 'quick and casual' decision-making.

METHODS

We asked clinicians to answer a cognitive puzzle to which there was an obvious, but incorrect, answer, to measure their propensity for 'quick and casual' decision-making. The same clinicians were also asked to report the number of clinical errors they had committed in the previous two weeks. We hypothesised an association between committing error and settling for an incorrect answer, and that the cognitive puzzle would have predictive capability.

RESULTS

90 of 153 (59%) clinicians reported that they had committed error, while 103 (67%) gave the incorrect 'intuitive' answer to the cognitive puzzle. There was no statistically significant difference between clinicians who committed error and answered incorrectly, and those who did not and answered correctly (χ2(1, n=1153)=0.021, p=0.885).

CONCLUSIONS

The prevalence of clinical error in our study was higher than previously reported in the literature, and the propensity for accepting intuitive solutions was high. Although the cognitive puzzle was unable to predict who was more likely to commit error, the study offers insights into developing other predictive models for error.

A Technological Innovation to Reduce Prescribing Errors Based on Implementation Intentions: The Acceptability and Feasibility of MyPrescribe

BACKGROUND

Although prescribing of medication in hospitals is rarely an error-free process, prescribers receive little feedback on their mistakes and ways to change future practices. Audit and feedback interventions may be an effective approach to modifying the clinical practice of health professionals, but these may pose logistical challenges when used in hospitals. Moreover, such interventions are often labor intensive. Consequently, there is a need to develop effective and innovative interventions to overcome these challenges and to improve the delivery of feedback on prescribing. Implementation intentions, which have been shown to be effective in changing behavior, link critical situations with an appropriate response; however, these have rarely been used in the context of improving prescribing practices.

OBJECTIVE

Semistructured qualitative interviews were conducted to evaluate the acceptability and feasibility of providing feedback on prescribing errors via MyPrescribe, a mobile-compatible website informed by implementation intentions.

METHODS

Data relating to 200 prescribing errors made by 52 junior doctors were collected by 11 hospital pharmacists. These errors were populated into MyPrescribe, where prescribers were able to construct their own personalized action plans. Qualitative interviews with a subsample of 15 junior doctors were used to explore issues regarding feasibility and acceptability of MyPrescribe and their experiences of using implementation intentions to construct prescribing action plans. Framework analysis was used to identify prominent themes, with findings mapped to the behavioral components of the COM-B model (capability, opportunity, motivation, and behavior) to inform the development of future interventions.

RESULTS

MyPrescribe was perceived to be effective in providing opportunities for critical reflection on prescribing errors and to complement existing training (such as junior doctors' e-portfolio). The participants were able to provide examples of how they would use "If-Then" plans for patient management. Technology, as opposed to other methods of learning (eg, traditional "paper based" learning), was seen as a positive advancement for continued learning.

CONCLUSIONS

MyPrescribe was perceived as an acceptable and feasible learning tool for changing prescribing practices, with participants suggesting that it would make an important addition to medical prescribers' training in reflective practice. MyPrescribe is a novel theory-based technological innovation that provides the platform for doctors to create personalized implementation intentions. Applying the COM-B model allows for a more detailed understanding of the perceived mechanisms behind prescribing practices and the ways in which interventions aimed at changing professional practice can be implemented.

Teaching Prescribing: Just What the Doctor Ordered? A Thematic Analysis of the Views of Newly Qualified Doctors

Undergraduate medical education has been criticised for failing to adequately prepare doctors for the task of prescribing. Pharmacists have been shown to improve medication use in hospitals. This study aims to elicit the views of intern doctors on the challenges of prescribing, and to suggest changes in education to enhance prescribing practice and potential role of the pharmacist. Semi-structured, qualitative interviews were conducted with intern doctors in their first year post qualification in an Irish hospital. Data collection was conducted until no new themes emerged and thematic analysis was performed. Thirteen interviews took place. Interns described training in practical prescribing as limited and felt the curriculum failed to convey the reality of actual prescribing. Pharmacists were perceived to be a useful, but underutilised, information source in the prescribing process. They requested an earlier introduction, and repeated exposure, to prescribing, and suggested the involvement of peers and pharmacists in this teaching. Intern doctors reported difficulties in applying knowledge gained in medical school to clinical practice. New strategies are needed to enhance the clinical relevance of the medical curriculum by rethinking the learning outcomes regarding prescribing practice and the involvement of pharmacists in prescribing education.

Prescribing Safety Assessment 2016: Delivery of a national prescribing assessment to 7343 UK final-year medical students

AIMS

Newly graduated doctors write a large proportion of prescriptions in UK hospitals but recent studies have shown that they frequently make prescribing errors. The prescribing safety assessment (PSA) has been developed as an assessment of competence in relation to prescribing and supervising the use of medicines. This report describes the delivery of the PSA to all UK final-year medical students in 2016 (PSA2016).

METHODS

The PSA is a 2-hour online assessment comprising eight sections which cover various aspects of prescribing defined within the outcomes of undergraduate education identified by the UK General Medical Council. Students sat one of four PSA 'papers', which had been standard-set using a modified Angoff process.

RESULTS

A total of 7343 final-year medical students in all 31 UK medical schools sat the PSA. The overall pass rate was 95% with the pass rates for the individual papers ranging from 93 to 97%. The PSA was re-sat by 261 students who had failed and 80% of those candidates passed. The internal consistency (Cronbach's alpha) of the four papers ranged from 0.74 to 0.77 (standard error of measurement 4.13-4.24%). There was a statistically significant variation in performance between medical school cohorts (F = 32.6, P < 0.001) and a strongly positive correlation in performance for individual schools between PSA2015 and PSA2016 (r = 0.79, 95% CI 0.61-0.90; P < 0.01).

CONCLUSIONS

PSA2016 demonstrated the feasibility of delivering a standardized national prescribing assessment online. The vast majority of UK final-year medical students were able to meet a prespecified standard of prescribing competence.

Preparedness of newly qualified doctors in Ireland for prescribing in clinical practice

AIM

The aim of the study was to investigate the level of preparedness of newly qualified Irish-trained doctors for prescribing, and to investigate their attitudes towards prescribing and prescribing education, through a national survey.

METHODS

A 29-item online survey was distributed to 686 newly qualified doctors 1 month prior to the completion of their first year of clinical practice (internship). Only graduates from Irish medical schools were included.

RESULTS

The response rate was 20.4% (n = 140; female : male 56%:44%). The majority of respondents felt confident in prescription writing (89%), medication history taking (81%) and accessing drug information in the hospital setting (80%). Only 58% of respondents felt confident in drug dose calculation, and 35% felt confident in preparing and administering drugs. When asked if their undergraduate medical education had prepared them for prescribing in clinical practice, 28% of respondents agreed. Confidence that their undergraduate education had prepared them was associated with receiving formal training in prescribing skills (P = 0.0045; 27% vs. 0%). Thirty-seven per cent of respondents agreed that they felt stressed about prescribing medications.

CONCLUSION

This survey of newly qualified doctors in Ireland found that only 28% of respondents agreed that their undergraduate medical education had prepared them for prescribing, which was comparable to a previous survey of UK medical students and graduates. Investigating confidence and preparedness for prescribing provides important insights for educators. Dedicated teaching of prescribing, with an emphasis on practical training and assessment, may help graduates to feel more prepared for the challenges of prescribing in the clinical setting.

'If no-one stops me, I'll make the mistake again': Changing prescribing behaviours through feedback; A Perceptual Control Theory perspective'

BACKGROUND

Doctors at all levels make prescribing errors which can prolong patients' hospital stay, increase the risk of death, and place a significant financial burden on the health system. Doctors have previously reported receiving little or no feedback on their prescribing errors. The effectiveness of feedback in modifying future practice varies widely, depending on how feedback is delivered. To date there is little evidence about why and how feedback interventions do or do not work. Behavioural theories can be used to evaluate this process and provide explanatory accounts to inform recommendations for future interventions.

OBJECTIVE

To explore the experiences of prescribers receiving different methods of feedback about their prescribing errors. Perceptual Control Theory (PCT) was used as a theoretical framework to explain which aspects of feedback were most likely to influence prescribing behaviour.

METHODS

A secondary analysis of 31 semi-structured qualitative interviews with junior doctors who had taken part one of three studies in which they received feedback on their prescribing errors. A hybrid approach to analysis involved inductive thematic analysis, and deductive a priori template of codes using PCT as a framework to guide data analysis and interpretation.

RESULTS

Feedback was most useful for learning and most likely to influence future prescribing behaviour when it was timely, and provided a comprehensive, contextualised benchmark to which participants could compare their prescribing behaviours and current level of knowledge. Group discussions and completing directly-observed prescribing event forms were thought most likely to impact future prescribing; email feedback alone was perceived as least effective in changing prescribing behaviour.

CONCLUSION

Feedback has the potential to change future prescribing behaviour. Behaviour change can only take place if prescribers are made aware of these discrepancies, either via providing appropriate reference values or benchmarks before mistakes are made, or by providing timely and comprehensive feedback after mistakes are made.

Piloting the United Kingdom 'Prescribing Safety Assessment' with pharmacist prescribers in Scotland

BACKGROUND

Prescribing is a complex task requiring considerable knowledge and skills. The Prescribing Safety Assessment (PSA) was developed by the British Pharmacological Society and the United Kingdom (UK) Medical Schools Council. Between February and June 2014, over 7000 final year medical students undertook the PSA, with an overall pass rate of 94%. Independent prescribing for suitably trained pharmacists was introduced in the UK in 2006. To date there has been little focus on any objective measures of prescribing safety.

OBJECTIVE

To determine the PSA performance of a pilot group of pharmacist prescribers in Scotland relative to medical students and to test the feasibility and acceptability of running the PSA.

METHODS

A group of 59 pharmacist prescribers took part in ten events. The PSA consisted of 30 questions to be completed over 60 min. All questions had been used in the 2014 assessments for final year medical students. The PSA was undertaken online under invigilated conditions, mirroring the medical student assessment. One month later, participants were invited to complete an online evaluation questionnaire.

RESULTS

The mean overall PSA scores (±SD) were 87.5% ± 8.7 (range 52-98) compared to a 88.5% for medical students. Based on an Angoff passmark of 76.0%, 53 pharmacists (89.8%) passed compared to an overall pass rate in PSA 2014 of 94%. Pharmacists performed equivalently to medical students in all assessment areas, with a slightly lower performance in the prescribing, drug monitoring and data interpretation questions offset by better performance in prescription review and adverse drug reactions. Feedback was positive in relation to appropriateness, relevance and level of difficulty of the PSA although several commented that they were practicing in very specific clinical areas.

CONCLUSION

These pilot events have benchmarked the PSA performance of pharmacist prescribers with final year medical students, and feedback confirmed feasibility and acceptability.

Pharmacist independent prescribing in secondary care: opportunities and challenges

In recent years a number of countries have extended prescribing rights to pharmacists in a variety of formats. The latter includes independent prescribing, which is a developing area of practice for pharmacists in secondary care. Potential opportunities presented by wide scale implementation of pharmacist prescribing in secondary care include improved prescribing safety, more efficient pharmacist medication reviews, increased scope of practice with greater pharmacist integration into acute patient care pathways and enhanced professional or job satisfaction. However, notable challenges remain and these need to be acknowledged and addressed if a pharmacist prescribing is to develop sufficiently within developing healthcare systems. These barriers can be broadly categorised as lack of support (financial and time resources), medical staff acceptance and the pharmacy profession itself (adoption, implementation strategy, research resources, second pharmacist clinical check). Larger multicentre studies that investigate the contribution of hospital-based pharmacist prescribers to medicines optimisation and patient-related outcomes are still needed. Furthermore, a strategic approach from the pharmacy profession and leadership is required to ensure that pharmacist prescribers are fully integrated into future healthcare service and workforce strategies.

A multifaceted intervention to reduce drug-related complications in surgical patients

AIM

The P-REVIEW study was a prospective, multicenter, open intervention study, designed to determine whether a multifaceted intervention of educating the prescriber combined with medication review and pharmaceutical visits to the ward by the hospital pharmacist could lead to a reduction in drug-related complications among surgical patients.

METHODS

A total of 6780 admissions of 5940 patients to surgical, urological and orthopaedic wards during the usual care period and 6484 admissions of 5711 patients during the intervention period were included. An educational programme covering pain management, antithrombotics, fluid and electrolyte management, prescription in case of renal insufficiency and antibiotics was developed. National and local hospital guidelines were included. Hospital pharmacists performed medication safety consultations, combining medication review of high-risk patients and a visit to the physician on the ward.

RESULTS

A significantly lower proportion of admissions with one or more clinically relevant, potentially preventable, drug-related problems (including death, temporary or sustained disability, increased length of hospital stay or readmission within 30 days) occurred in the intervention period (1.1% (73/6484) compared to the usual care period [1.6% (106/6780)] (P = 0.029). The relative risk (RR) was 0.72 (95% CI 0.53-0.97). Several types of drug-related problems occurred less frequently. Costs incurred as result of time spent on study-related activities were not different before and after the intervention.

CONCLUSIONS

The P-REVIEW study shows that education and support of the prescribing physician with respect to high-risk patients in surgical departments leads to a significant, clinically relevant benefit for patients without generating additional costs.

Safe prescribing training provision for junior doctors: is this optimal?

BACKGROUND

The aim of this study was to determine the training provisions in practical safe prescribing for foundation doctors in NHS hospitals located in the South Thames region.

METHODS

A web-based questionnaire was distributed by e-mail to all 1762 foundation doctors in the South Thames Foundation School (STFS) region. In addition, a separate questionnaire was distributed to prescribing training Leads at 15 NHS Hospital Trusts. Quantitative data were analysed using descriptive statistics and thematic analysis was performed on qualitative data.

RESULTS

Trainers: 10 Prescribing Leads (67 %) responded. Of the 9 NHS Trusts that offered safe prescribing training in their induction programme, 5 included a practical prescribing session. By the end of the foundation year, 6 NHS Trusts had provided at least one dedicated practical prescribing session for F1s compared with 2 NHS Trusts for F2s. Trainees: A total of 124 foundation trainees (7.2 %) responded (69 F1s and 55 F2s). 87 % of F1s received dedicated training in safe prescribing at their Trust induction (n = 60) in comparison to 49 % of F2s (n = 27). 80 % of F1s (n = 55) had a practical prescribing session during induction versus 27 % of F2s (n = 15). The difference was significant, X (2) (1, N = 124) = 34.23, p <0.0001. Emerging themes from qualitative data included, recognition of medical education as a continuum, importance of working relationships with pharmacists and neglect of F2s.

CONCLUSIONS

There appears to be a lack of emphasis on the training of F2 doctors in practical safe prescribing compared with F1 doctors. There should be standardisation of safe prescribing training provisions, particularly in the induction period and for F2 doctors.

Factors Influencing Successful Prescribing by Intern Doctors: A Qualitative Systematic Review

As the majority of prescribing in hospital is undertaken by intern doctors, the aims of this systematic review were to compile the evidence of the qualitative literature on the views and experiences of intern doctors and to examine the role of the pharmacist in assisting in prescribing by interns. A systematic review of the qualitative literature was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The findings were synthesized using thematic analysis. Seven publications were included. Factors influencing prescribing behaviour were related to the environment; collaboration in medical teams; hierarchical structures; and patient and individual factors. This review confirmed that interns’ prescribing behaviour is influenced by multiple factors, and further highlighted the need for an educational intervention that supports the intern completing the prescribing task in a complex environment, and not just addresses the presumed knowledge gap(s).