Benefit of targeted, pharmacist-led education for junior doctors in reducing prescription writing errors - a controlled trial

Can a novel constructivist theory-informed feedback intervention reduce prescribing errors ? A pre-post study

CONTEXT

Medical interns (interns) find prescribing challenging and many report lacking readiness when commencing work. Errors in prescribing puts patients' safety at risk. Yet error rates remain high, despite education, supervision and pharmacists' contributions. Feedback on prescribing may improve performance. Yet, work-based prescribing feedback practices focus on rectifying errors. We aimed to explore if prescribing can be improved using a theory-informed feedback intervention.

METHODS

In this pre-post study, we designed and implemented a constructivist-theory informed prescribing feedback intervention, informed by Feedback-Mark 2 Theory. Interns commencing internal medicine terms in two Australian teaching hospitals were invited to engage in the feedback intervention. Their prescribing was evaluated by comparing errors per medication order of at least 30 orders per intern. Pre/baseline (weeks 1-3) were compared with post intervention (weeks 8-9). Interns' baseline prescribing audit findings were analysed and discussed at individualised feedback sessions. These sessions were with a clinical pharmacologist (Site 1) and a pharmacist educator (Site 2).

RESULTS

Eighty eight intern's prescribing over five 10-week terms was analysed from two hospitals. The frequency of prescribing errors significantly reduced at both sites after the intervention, across all five terms (p < 0.001).There were initially 1598 errors in 2750 orders (median [IQR] 0.48 [0.35-0.67] errors per order) and after the intervention 1113 errors in 2694 orders (median [IQR] 0.30 [0.17-0.50] errors per order).

CONCLUSION

Our findings suggest interns' prescribing practices may improve as a result of constructivist -theory learner centred, informed feedback with an agreed plan. This novel intervention, contributed, to a reduction in interns' prescribing errors. This study suggests new strategies for improving prescribing safety should include the design and implementation of theory-informed feedback interventions.

Methods of Detecting Medication Administration Point-of-Care Errors in Acute Adult Inpatient Settings: A Scoping Review Protocol

Medication administration is recognized as a risk-prone activity where errors and near misses have multiple opportunities to occur along the route from manufacturing, through transportation, storage, prescription, dispensing, point-of-care administration, and post-administration documentation. While substantial research, education, and tools have been invested in the detection of medication errors on either side of point-of-care administration, less attention has been placed on this finite phase, leaving a gap in the error detection process. This protocol proposes to undertake a scoping review of the literature related to the detection of medication errors at the point-of-care to understand the potential size, nature, and extent of available literature. The aim is to identify research evidence to guide clinical practice and future research at the medication and patient point-of-care intersection. The search strategy will review literature from PubMed, CINAHL, Cochrane Collaboration, Embase, Scopus, PsychInfo, Web of Science, TRIP, TROVE, JBI Systematic Reviews, Health Collection (Informit), Health Source Nursing Academic, Prospero, Google Scholar, and graylit.org dated 1 January 2000–31 December 2021. Two independent reviewers will screen the literature for relevancy to the review objective, and critically appraise the citations for quality, validity, and reliability using the Joanna Briggs scoping review methodology and System for Unified Management, Assessment and Review of Information (SUMARI) tool. The data will be systematically synthesized to identify and compare the medication error administration detection method findings. A descriptive narrative discussion will accompany the findings.

Reducing medication errors for adults in hospital settings

BACKGROUND

Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death.

OBJECTIVES

To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible.  MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131).  Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724).  Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311).  Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88).  Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775).

AUTHORS' CONCLUSIONS

Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis

INTRODUCTION

Medication errors are avoidable events that can occur at any stage of the medication use process. They are widespread in healthcare systems and are linked to an increased risk of morbidity and mortality. Several strategies have been studied to reduce their occurrence including different types of pharmacy-based interventions. One of the main pharmacist-led interventions is educational programs, which seem to have promising benefits.

OBJECTIVE

To describe and compare various pharmacist-led educational interventions delivered to healthcare providers and to evaluate their impact qualitatively and quantitatively on medication error rates.

METHODS

A systematic review and meta-analysis was conducted through searching Cochrane Library, EBSCO, EMBASE, Medline and Google Scholar from inception to June 2020. Only interventional studies that reported medication error rate change after the intervention were included. Two independent authors worked through the data extraction and quality assessment using Crowe Critical Appraisal Tool (CCAT). Summary odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of medication errors. Research protocol is available in The International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42019116465.

RESULTS

Twelve studies involving 115058 participants were included. The two main recipients of the educational interventions were nurses and resident physicians. Educational programs involved lectures, posters, practical teaching sessions, audit and feedback method and flash cards of high-risk abbreviations. All studies included educational sessions as part of their program, either alone or in combination with other approaches, and most studies used errors encountered before implementing the intervention to inform the content of these sessions. Educational programs led by a pharmacist were associated with significant reductions in the overall rate of medication errors occurrence (OR, 0.38; 95% CI, 0.22 to 0.65).

CONCLUSION

Pharmacist-led educational interventions directed to healthcare providers are effective at reducing medication error rates. This review supports the implementation of pharmacist-led educational intervention aimed at reducing medication errors.

Interventions to reduce medication errors in adult medical and surgical settings: a systematic review

Background and Aims:

Medication errors occur at any point of the medication management process, and are a major cause of death and harm globally. The objective of this review was to compare the effectiveness of different interventions in reducing prescribing, dispensing and administration medication errors in acute medical and surgical settings.

Methods:

The protocol for this systematic review was registered in PROSPERO (CRD42019124587). The library databases, MEDLINE, CINAHL, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched from inception to February 2019. Studies were included if they involved testing of an intervention aimed at reducing medication errors in adult, acute medical or surgical settings. Meta-analyses were performed to examine the effectiveness of intervention types.

Results:

A total of 34 articles were included with 12 intervention types identified. Meta-analysis showed that prescribing errors were reduced by pharmacist-led medication reconciliation, computerised medication reconciliation, pharmacist partnership, prescriber education, medication reconciliation by trained mentors and computerised physician order entry (CPOE) as single interventions. Medication administration errors were reduced by CPOE and the use of an automated drug distribution system as single interventions. Combined interventions were also found to be effective in reducing prescribing or administration medication errors. No interventions were found to reduce dispensing error rates. Most studies were conducted at single-site hospitals, with chart review being the most common method for collecting medication error data. Clinical significance of interventions was examined in 21 studies. Since many studies were conducted in a pre–post format, future studies should include a concurrent control group.

Conclusion:

The systematic review identified a number of single and combined intervention types that were effective in reducing medication errors, which clinicians and policymakers could consider for implementation in medical and surgical settings. New directions for future research should examine interdisciplinary collaborative approaches comprising physicians, pharmacists and nurses.

Lay summary

Activities to reduce medication errors in adult medical and surgical hospital areas

Introduction:

Medication errors or mistakes may happen at any time in hospital, and they are a major reason for death and harm around the world.

Objective:

To compare the effectiveness of different activities in reducing medication errors occurring with prescribing, giving and supplying medications in adult medical and surgical settings in hospital.

Methods:

Six library databases were examined from the time they were developed to February 2019. Studies were included if they involved testing of an activity aimed at reducing medication errors in adult medical and surgical settings in hospital. Statistical analysis was used to look at the success of different types of activities.

Results:

A total of 34 studies were included with 12 activity types identified. Statistical analysis showed that prescribing errors were reduced by pharmacists matching medications, computers matching medications, partnerships with pharmacists, prescriber education, medication matching by trained physicians, and computerised physician order entry (CPOE). Medication-giving errors were reduced by the use of CPOE and an automated medication distribution system. The combination of different activity types were also shown to be successful in reducing prescribing or medication-giving errors. No activities were found to be successful in reducing errors relating to supplying medications. Most studies were conducted at one hospital with reviewing patient charts being the most common way for collecting information about medication errors. In 21 out of 34 articles, researchers examined the effect of activity types on patient harm caused by medication errors. Many studies did not involve the use of a control group that does not receive the activity.

Conclusion:

A number of activity types were shown to be successful in reducing prescribing and medication-giving errors. New directions for future research should examine activities comprising health professionals working together.

Accuracy checking of dispensed medications by a pharmacy technician: a hospital case study

Medication order accuracy checking is an integral and time-consuming component of the current Australian pharmacist's role. However, the pharmacy profession internationally has moved towards separating the checking task into two parts: a clinical check performed by the registered pharmacist and a technical accuracy check delegated to an appropriately trained pharmacy technician. This case study demonstrates that in an Australian hospital pharmacy context, appropriately trained pharmacy technicians have the potential to be more proficient and time efficient than pharmacists when undertaking accuracy checking of dispensed medications.

Digital Learning to Improve Safe and Effective Prescribing: A Systematic Review

With the aim to modernize and harmonize prescribing education, the European Association for Clinical Pharmacology and Therapeutics (EACPT) Working Group on education recommended the extensive use and distribution of digital learning resources (DLRs). However, it is unclear whether the complex task of prescribing medicine can be taught digitally. Therefore, the aim of this review was to investigate the effect of diverse DLRs in clinical pharmacology and therapeutics education. Databases PubMed, EMBASE, CINAHL, ERIC, and CENTRAL were systematically searched. Sixty-five articles were included in the analyses. Direct effects on patients were studied, but not detected, in six articles. Skills and behavior were studied in 11 articles, 8 of which reported positive effects. Knowledge acquisition was investigated in 19 articles, all with positive effects. Qualitative analyses yielded 10 recommendations for the future development of DLRs. Digital learning is effective in teaching knowledge, attitudes, and skills associated with safe and effective prescribing.

A pilot study of a pharmacist-led prescribing program for final-year medical students

BACKGROUND

Junior doctors undertake a significant amount of prescribing; however, they are not well prepared for this, and report they would like more training in their undergraduate courses. To address this we tested a pharmacist-led prescribing program for final-year medical students.

METHODS

Sixteen final-year students took part in the program. The program involved students writing prescriptions and getting feedback from clinical pharmacists, undertaking prescribing and calculation tutorials, and spending time in the pharmacy department. Evaluation included a pre- and post-assessment of their confidence and skills in prescribing, and a feedback session discussing the strengths and weakness of the program, and their perceptions about the role of pharmacists. Changes in the pre- and post-assessment of confidence and skills were examined with permutation and Mann-Whitney U tests.

RESULTS

There was a significant improvement in students' confidence in prescribing, and a small but consistent improvement in prescribing skills. Of note, no student prescribed inappropriately and potentially harmfully after the program. Participants were positive about the program, and indicated a better understanding about the pharmacists' role and their ability to support them as junior doctors.

CONCLUSIONS

This study has shown the potential effect of a pharmacist-led prescribing program on the skills and confidence in prescribing by medical students. It provided an interprofessional teaching opportunity, preparing students for a team-based approach to patient management.