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Alanzi MA, Tully MP, Lewis PJ. Exploring the challenges faced by foundation doctors when prescribing high risk medicines safely during the on-call period: A qualitative study. Br J Clin Pharmacol 2024; 90:548-556. [PMID: 37872107 DOI: 10.1111/bcp.15928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 10/05/2023] [Accepted: 10/08/2023] [Indexed: 10/25/2023] Open
Abstract
AIMS Errors with prescribing high-risk medicines (HRMs) have a greater propensity to cause harm than with non-HRMs. Prescribing errors arise due to multiple factors and it can be particularly challenging for junior doctors to prescribe safely during the on-call period. Knowledge regarding the challenges of prescribing HRM during the on-call period would be useful to target preventative interventions. The aim of this study was to explore the challenges encountered by foundation doctors (doctors who have graduated medical school within the last 2 years) when prescribing specific HRMs (anticoagulants, insulin and opioids) safely during the on-call period. METHODS Six focus groups exploring the challenges of prescribing HRMs safely during the on-call period were conducted, 3 with foundation year 1 and 3 with foundation year 2 doctors from across 3 different hospitals. A thematic framework analysis based on the London Protocol was conducted. RESULTS Doctors described multiple challenges to prescribing HRMs safely during the on-call period including a lack of prescribing support, nursing pressure, complex prescribing tasks, unknown patients as well as individual factors such as lack of knowledge and tiredness. Many of these factors exist to some extent during the day, yet the nature of the on-call period as a fast-paced environment heightened the challenges that prescribers faced. CONCLUSION There are multiple challenges experienced by foundation doctors when prescribing HRMs during the on-call period. The potentially devastating consequences of errors with HRMs means that closer attention and more concern from healthcare professionals, researchers and policymakers is required to improve safe prescribing of HRMs in hospitals.
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Affiliation(s)
- Mahdi A Alanzi
- Department of Pharmaceutical Services, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia
| | - Mary P Tully
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Penny J Lewis
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
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2
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Babar P, Qaiser U, Rehman IU. Assessment of prescription writing skills among dental house officers: A multi-center study. Pak J Med Sci 2024; 40:170-173. [PMID: 38196487 PMCID: PMC10772446 DOI: 10.12669/pjms.40.1.7688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 08/08/2023] [Accepted: 09/02/2023] [Indexed: 01/11/2024] Open
Abstract
Objective To assess the knowledge and skills of prescription writing among dental house officers from different hospitals. Methods This cross-sectional study was conducted from July to September, 2022. A self-administered, structured questionnaire was used to collect data from 180 house officers from four teaching dental hospitals (n=45 each). The participants were asked to write a prescription for an adult and a pediatric patient. The prescription was evaluated according to WHO criteria. Analysis was done using SPSS v.20. Data was presented as frequencies and percentages. Results Among the 180 participants, 42.9% were males and 57.1% were females. 33.9% participants reported prescription writing to be a difficult task. Only 36.7% participants reported to be trained in prescribing pediatric medications. None of the prescriptions completely fulfilled the WHO criteria. Doctor related information (name, address and contact no) was written by only 3.8% of the participants while 10% of the participants mentioned the patient related information (name, address and age). Dosage of the prescribed drugs was the most commonly drug-related missing parameter which was mentioned in 30% of the pediatric prescriptions and 21% of the adult prescriptions. Conclusion There is a general lack of knowledge among the dental house officers regarding prescription writing as they were found to be unaware of the essential elements of a prescription. The findings call for an urgent change in the undergraduate teaching of prescription writing skills with special emphasis on pediatric drugs and dosage.
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Affiliation(s)
- Palwasha Babar
- Palwasha Babar, MDS Assistant Professor, Department of Paediatric Dentistry, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, Pakistan
| | - Uswa Qaiser
- Uswa Qaiser, BDS Demonstrator, Department of Operative and Pediatric Dentistry, University College of Dentistry, The University of Lahore, Lahore, Pakistan
| | - Ijaz ur Rehman
- Ijaz ur Rehman, FCPS Assistant Professor, Department of Oral Medicine, University College of Dentistry, The University of Lahore, Lahore, Pakistan
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3
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Ayre MJ, Lewis PJ, Phipps DL, Keers RN. unDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in community caRe (DISCOVER): a qualitative study. Front Psychiatry 2023; 14:1241445. [PMID: 38144479 PMCID: PMC10746165 DOI: 10.3389/fpsyt.2023.1241445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Background It is estimated that 237 million medication errors occur in England each year with a significant number occurring in the community. Our understanding of the causes of preventable medication errors and adverse drug events (ADE) affecting patients with mental illness is limited in this setting. Better understanding of the factors that contribute to errors can support the development of theory-driven improvement interventions. Methods Remote qualitative semi-structured interviews with 26 community-based healthcare professionals in England and Wales were undertaken between June-November 2022. Recruitment was undertaken using purposive sampling via professional networks. Interviews were guided by the critical incident technique and analysed using the framework method. Any data that involved speculation was not included in the analysis. Independent analysis was carried out by the research team to extract themes guided by the London Protocol. Results A total of 43 medication errors and 12 preventable ADEs were discussed, with two ADEs having an unknown error origin. Prescribing errors were discussed most commonly (n = 24), followed by monitoring errors (n = 8). Six contributory factor themes were identified: the individual (staff); the work environment; the teams/interfaces; the organisation and management; the patient; and the task and technology. The individual (staff) factors were involved in just over 80% of all errors discussed. Participants reported a lack of knowledge regarding psychotropic medication and mental illnesses which accompanied diffusion of responsibility. There were difficulties with team communication, particularly across care interfaces, such as ambiguity/brevity of information being communicated and uncertainty concerning roles which created confusion amongst staff. Unique patient social/behavioural contributory factors were identified such as presenting with challenging behaviour and complex lifestyles, which caused difficulties attending appointments as well as affecting overall clinical management. Conclusion These findings highlight that the causes of errors are multifactorial with some unique to this patient group. Key areas to target for improvement include the education/training of healthcare professionals regarding neuropharmacology/mental illnesses and enhancing communication across care interfaces. Future research should explore patient perspectives regarding this topic to help develop a holistic picture. These findings can be used to guide future intervention research to ameliorate medication safety challenges for this patient group.
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Affiliation(s)
- Matthew J. Ayre
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Penny J. Lewis
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, United Kingdom
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Denham L. Phipps
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, United Kingdom
| | - Richard N. Keers
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, United Kingdom
- Optimising Outcomes with Medicines (OptiMed) Research Unit, Pennine Care NHS Foundation Trust, Manchester, United Kingdom
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Blamey H, Harrison CH, Roddick A, Malhotra T, Saunders KEA. Simulated virtual on-call training programme for improving non-specialised junior doctors' confidence in out-of-hours psychiatry: quantitative assessment. BJPsych Bull 2023; 47:287-295. [PMID: 36073524 PMCID: PMC10764820 DOI: 10.1192/bjb.2022.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/25/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022] Open
Abstract
AIMS AND METHOD To investigate whether a psychiatry-specific virtual on-call training programme improved confidence of junior trainees in key areas of psychiatry practice. The programme comprised one 90 min lecture and a 2 h simulated on-call shift where participants were bleeped to complete a series of common on-call tasks, delivered via Microsoft Teams. RESULTS Thirty-eight trainees attended the lecture, with a significant improvement in confidence in performing seclusion reviews (P = 0.001), prescribing psychiatric medications for acute presentations (P < 0.001), working in section 136 suites (places of safety) (P = 0.001) and feeling prepared for psychiatric on-call shifts (P = 0.002). Respondents reported that a virtual on-call practical session would be useful for their training (median score of 7, interquartile range 5-7.75). Eighteen participants completed the virtual on-call session, with significant improvement in 9 out of the 10 tested domains (P < 0.001). CLINICAL IMPLICATIONS The programme can be conducted virtually, with low resource requirements. We believe it can improve trainee well-being, patient safety, the delivery of training and induction of rotating junior doctors during the COVID-19 pandemic and it supports the development and delivery of practical training in psychiatry.
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Affiliation(s)
- Helen Blamey
- John Radcliffe Hospital, Oxford, UK
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK
| | - Charlotte H. Harrison
- John Radcliffe Hospital, Oxford, UK
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK
| | - Alistair Roddick
- John Radcliffe Hospital, Oxford, UK
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK
| | | | - Kate E. A. Saunders
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
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5
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Kalfsvel L, Wilkes S, van der Kuy H, van den Broek W, Zaal R, van Rosse F, Versmissen J. Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study. Eur J Hosp Pharm 2023:ejhpharm-2023-003859. [PMID: 37652663 DOI: 10.1136/ejhpharm-2023-003859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/08/2023] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVES Prescribing errors can lead to inconvenience, morbidity and mortality. It is therefore crucial to educate doctors to prescribe safely, efficiently and effectively. To create an effective educational programme, it is essential to understand which errors are made and by whom. The aim of this study is to explore if the experience level of the doctor influences how many and which prescribing errors are made in a European academic teaching hospital, where a computerised physician order entry system (CPOE) with a clinical decision support system (CDSS) is exclusively used. METHODS Prescriptions for all inpatients in an academic teaching hospital were collected in June 2021. All prescriptions with an alert generated by the CDSS which could not be handled by a pharmacy technician according to local protocol were checked for errors. Identified errors were categorised by type and severity. RESULTS A total of 130 538 prescriptions were newly made or altered by doctors. Of these prescriptions, 1914 (1.5%) were retained for a check by the pharmacist. These contained 430 prescribing errors (0.3% of total prescriptions). Doctors not in specialty training and those in specialty training made more prescribing errors than consultants (0.5% and 0.5% vs 0.1%; p<0.001). Doctors in specialty training made relatively more drug-drug interaction errors than consultants (n=31 (16%) vs n=3 (3%), p<0.05). No significant difference was found regarding the severity of the errors. CONCLUSIONS Doctors not in specialty training and doctors in specialty training, who are the less experienced doctors, make more prescribing errors than consultants, even with the use of a CPOE combined with CDSS. The type of errors differ between doctors of different experience levels. This finding provides a solid basis for specific additional education to medical students, doctors not in specialty training and doctors in specialty training.
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Affiliation(s)
| | - Sarah Wilkes
- Hospital Pharmacy, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Rianne Zaal
- Hospital Pharmacy, Erasmus MC, Rotterdam, Netherlands
| | | | - Jorie Versmissen
- Hospital Pharmacy, Erasmus MC, Rotterdam, Netherlands
- Internal Medicine, Erasmus MC, Rotterdam, Netherlands
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6
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Donker EM, Pandit R, Poleij MCS, Brinkman DJ, van Agtmael MA, van Rosse F, Dumont G, Kramers C, Atiqi R, Richir MC, van Smeden J, Hessel MHM, Janssen BJ, Knol W, Tichelaar J. The Dutch list of essential drugs for undergraduate medical education: A modified Delphi study. Br J Clin Pharmacol 2023; 89:1431-1451. [PMID: 36403122 DOI: 10.1111/bcp.15606] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022] Open
Abstract
AIMS Prescribing errors among junior doctors are common in clinical practice because many lack prescribing competence after graduation. This is in part due to inadequate education in clinical pharmacology and therapeutics (CP&T) in the undergraduate medical curriculum. To support CP&T education, it is important to determine which drugs medical undergraduates should be able to prescribe safely and effectively without direct supervision by the time they graduate. Currently, there is no such list with broad-based consensus. Therefore, the aim was to reach consensus on a list of essential drugs for undergraduate medical education in the Netherlands. METHODS A two-round modified Delphi study was conducted among pharmacists, medical specialists, junior doctors and pharmacotherapy teachers from all eight Dutch academic hospitals. Participants were asked to indicate whether it was essential that medical graduates could prescribe specific drugs included on a preliminary list. Drugs for which ≥80% of all respondents agreed or strongly agreed were included in the final list. RESULTS In all, 42 (65%) participants completed the two Delphi rounds. A total of 132 drugs (39%) from the preliminary list and two (3%) newly proposed drugs were included. CONCLUSIONS This is the first Delphi consensus study to identify the drugs that Dutch junior doctors should be able to prescribe safely and effectively without direct supervision. This list can be used to harmonize and support the teaching and assessment of CP&T. Moreover, this study shows that a Delphi method is suitable to reach consensus on such a list, and could be used for a European list.
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Affiliation(s)
- Erik M Donker
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Rahul Pandit
- Department of Translational Neuroscience, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - Merel C S Poleij
- Department of Translational Neuroscience, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - David J Brinkman
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Floor van Rosse
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Glenn Dumont
- Department of Clinical Pharmacology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cornelis Kramers
- Department of Pharmacology and Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Clinical Pharmacy, CWZ, Nijmegen, The Netherlands
| | - Roya Atiqi
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Milan C Richir
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen van Smeden
- Centre for Human Drug Research, Leiden, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands.,Leiden Academic Centre for Drug Research, University of Leiden, Leiden, The Netherlands
| | - Marleen H M Hessel
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ben J Janssen
- Department of Pharmacology and Toxicology, Maastricht University, Maastricht, The Netherlands
| | - Wilma Knol
- Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jelle Tichelaar
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
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7
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Kalfsvel L, Hoek K, Bethlehem C, van der Kuy H, van den Broek WW, Versmissen J, van Rosse F. How would final-year medical students perform if their skill-based prescription assessment was real life? Br J Clin Pharmacol 2022; 88:5202-5217. [PMID: 35653185 PMCID: PMC9796372 DOI: 10.1111/bcp.15427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 01/01/2023] Open
Abstract
AIMS Prescribing errors occur frequently, especially among junior doctors. Our aim was to investigate prescribing errors made by final-year medical students. Information on these errors can help to improve education on and assessment of clinical pharmacotherapy (CPT). METHODS This was a retrospective cohort study amongst final-year medical students at Erasmus Medical Centre, The Netherlands. Errors made in the final prescribing assessment were analysed. Errors were categorized by type, possible consequence and possibility of reaching the patient in real life. RESULTS A total of 381 students wrote 1502 analysable prescriptions. Forty per cent of these contained at least one error, and 54% of errors were of the inadequate information type. The rating of prescriptions for children was lower than for other question categories (P = <.001). Fifty per cent of errors were classified as "would have reached the patient but would not have had the potential to cause harm". In total, 253 (29%) errors would not have been intercepted by an electronic prescribing system or a pharmacist. Ten (4%) of these would probably have caused harm in the patient. CONCLUSIONS There is a high rate of errors in prescriptions written by final-year medical students. Most errors were of the inadequate information type, indicating that students had difficulties determining the content and amount of information needed to make treatment successful. Prescriptions for children contained most errors. Curricula could be improved by offering more case-based CPT education, focusing on the practical issues of prescribing, especially for paediatric cases, and offering more practice time for prescribing during clerkships.
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Affiliation(s)
- Laura Kalfsvel
- Erasmus Medical CentreUniversity Medical Center Rotterdam, Hospital PharmacyRotterdamThe Netherlands
| | - Kirsten Hoek
- Erasmus Medical CentreUniversity Medical Center Rotterdam, Hospital PharmacyRotterdamThe Netherlands
| | - Corine Bethlehem
- Erasmus Medical CentreUniversity Medical Center Rotterdam, Hospital PharmacyRotterdamThe Netherlands
| | - Hugo van der Kuy
- Erasmus Medical CentreUniversity Medical Center Rotterdam, Hospital PharmacyRotterdamThe Netherlands
| | - Walter W. van den Broek
- Erasmus Medical CentreUniversity Medical Center Rotterdam, Institute of Medical Education Research RotterdamRotterdamThe Netherlands
| | - Jorie Versmissen
- Erasmus Medical CentreUniversity Medical Center Rotterdam, Hospital PharmacyRotterdamThe Netherlands,Erasmus Medical CentreUniversity Medical Center Rotterdam, Department of Internal MedicineRotterdamThe Netherlands
| | - Floor van Rosse
- Erasmus Medical CentreUniversity Medical Center Rotterdam, Hospital PharmacyRotterdamThe Netherlands
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8
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Hashmi H, Sasoli NA, Sadiq A, Raziq A, Batool F, Raza S, Iqbal Q, Haider S, Umer Jan S, Mengal MA, Tareen AM, Khalid A, Saleem F. Prescribing Patterns for Upper Respiratory Tract Infections: A Prescription-Review of Primary Care Practice in Quetta, Pakistan and the Implications. Front Public Health 2021; 9:787933. [PMID: 34869195 PMCID: PMC8640527 DOI: 10.3389/fpubh.2021.787933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background: To identify and address the potential overuse of antibiotics, it is important to ascertain the prescribing practices of physicians. We, therefore, conducted this prescription analysis to document URTI-specific antibiotic prescription frequency in a public primary healthcare setting of Quetta city, Pakistan. Methods: A retrospective record review was conducted of all prescriptions for URTIs in Combined Military Hospital, Quetta from 1 March to 31st May 2021. The Mann-Whitney U and Jonckheere–Terpstra test was used to evaluate the association between the tendencies of a different group of prescribers. p-value of <0.05 was of statistical significance. Results: Over the 3 months, 50,705 prescriptions were screened and analyzed according to the established inclusion and exclusion criteria. A total of 4,126 (8.13%) URTI prescriptions met the inclusion criteria, of which 2,880 (69.80%) prescriptions contained antibiotics. Among all antibiotics, penicillins (Amoxicillin + Clavulanate) were the most prescribed antibiotic, constituting 1,323 (45.9%) of total antibiotics prescribed for all cases, followed by the Macrolide group 527 (18.2%). The Jonckheere–Terpstra test revealed a statistically significant association between the status of the prescriber and the diagnosis (p = 0.002). Furthermore, a moderate positive trend was reported with specialists being more competent in antibiotic prescribing based on their diagnosis, followed by postgraduates and house officers (τ = 0.322). Conclusion: The prescribing patterns for the management of URTIs in the hospital were inconsistent with current guidelines. Strict adherence to guidelines must be ensured and antibiotic prescribing for URTIs should be discouraged.
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Affiliation(s)
- Hania Hashmi
- Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta, Pakistan
| | | | - Abdul Sadiq
- Department of Biochemistry, Jhalawan Medical College Khuzdar, Khuzdar, Pakistan
| | - Abdul Raziq
- Department of Statistics, University of Baluchistan, Quetta, Pakistan
| | - Fakhra Batool
- Department of Pharmacy, Sardar Bahadur Khan Women's University, Quetta, Pakistan
| | - Shanaz Raza
- Department of Pharmacy, Sardar Bahadur Khan Women's University, Quetta, Pakistan
| | - Qaiser Iqbal
- Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Sajjad Haider
- Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Syed Umer Jan
- Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Muhammad Alam Mengal
- Center for Advanced Studies in Vaccinology and Biotechnology, University of Baluchistan, Quetta, Pakistan
| | | | - Adnan Khalid
- Department of Surgery, Combined Military Hospital, Quetta, Pakistan
| | - Fahad Saleem
- Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta, Pakistan
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9
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Tran T, Taylor SE, George J, Chan V, Mitri E, Elliott RA. Pharmacist‐assisted prescribing in an Australian hospital: a qualitative study of hospital medical officers’ and nursing staff perspectives. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2021. [DOI: 10.1002/jppr.1766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Tim Tran
- Pharmacy Department Austin Health Heidelberg Australia
- Centre for Medicine Use and Safety Faculty of Pharmacy and Pharmaceutical Sciences Monash University Parkville Australia
| | | | - Johnson George
- Centre for Medicine Use and Safety Faculty of Pharmacy and Pharmaceutical Sciences Monash University Parkville Australia
| | - Vincent Chan
- Pharmacy Department Austin Health Heidelberg Australia
- Pharmacy School of Health and Biomedical Sciences RMIT University Bundoora Australia
| | - Elise Mitri
- Pharmacy Department Austin Health Heidelberg Australia
| | - Rohan A. Elliott
- Pharmacy Department Austin Health Heidelberg Australia
- Centre for Medicine Use and Safety Faculty of Pharmacy and Pharmaceutical Sciences Monash University Parkville Australia
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10
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Kalfsvel L, Versmissen J, van Doorn A, van den Broek W, van der Kuy H, van Rosse F. Better performance of medical students on pharmacotherapy knowledge and skills tests is associated with practising with e-learning program P-scribe. Br J Clin Pharmacol 2021; 88:1334-1346. [PMID: 34505717 PMCID: PMC9293177 DOI: 10.1111/bcp.15077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/19/2021] [Accepted: 08/28/2021] [Indexed: 12/03/2022] Open
Abstract
Aims Junior doctors write most hospital prescriptions, yet are more than twice as likely to make an error in their prescriptions compared to senior doctors. A possibility to enhance pharmacotherapy education is through the use of e‐learning modules. The aim of this study was to determine whether P‐scribe, as the chosen e‐learning resource, helps students in passing their pharmacotherapy assessments. Methods This retrospective study was undertaken in the Erasmus Medical Center, the Netherlands. All 270 medical students who started their master's curriculum in the academic session of 2017–2018 were included. Data were analysed to identify the frequency of student's use per e‐learning module, total time students spent on e‐learning modules and timing of the use of e‐learning modules in relation to their assessments. The results of the assessments were analysed to identify possible correlations between the time students spent using P‐scribe, their timing of use and their assessment results. Results Students who passed their knowledge‐based assessment first time had a mean practice time of five more hours than students who did not pass first time (P < .05, 95% CI: 3.4–6.6). These students practised on average six e‐learning modules more (P < .05, 95% CI: 4.1–7.0) than students who failed their first attempt. Students who passed their skill‐based prescription test first time, practised on average five more e‐learning modules (P = .006, 95% CI: 1.4–8.3) than students who failed their first attempt. Conclusion Students who passed their pharmacotherapy assessments first time spent more time, and practised more frequently, with e‐learning modules.
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Affiliation(s)
- Laura Kalfsvel
- Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jorie Versmissen
- Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Adriaan van Doorn
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Walter van den Broek
- Erasmus MC, University Medical Center Rotterdam, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - Hugo van der Kuy
- Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Floor van Rosse
- Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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11
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Sullivan HW, Squire C, Aikin KJ, Tzeng J, Ferriola-Bruckenstein K, Brodsky E, Trentacosti AM, Johnson M. Physicians' use of and preferences for FDA-approved prescribing information. Res Social Adm Pharm 2021; 18:3027-3037. [PMID: 34364803 DOI: 10.1016/j.sapharm.2021.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/30/2021] [Accepted: 07/31/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Prescribing Information (PI) is the US Food and Drug Administration (FDA)'s primary tool for communicating a summary of the essential scientific information needed for the safe and effective use of a prescription drug to healthcare providers.[1] One challenge with this type of communication is balancing the need to be thorough with the need to be concise. OBJECTIVES This study aimed to explore physicians' preferences for and understanding of specific content and formatting in the PI. This study also explored physicians' use of and perceptions of the PI. METHODS Seventy semi-structured qualitative interviews were conducted with primary care physicians (n = 35) and physicians from a wide range of specialties (n = 35) using web conferencing technology. Using fictitious PI examples, the guide assessed physicians' interpretation of language and preferences for how certain information is organized and communicated in select sections of the PI. The interview guide also included questions about the resources physicians use to find information about prescription drugs, when and how physicians access the PI, and their perceptions of the PI. RESULTS The findings suggest that of the content and formatting items surveyed, physicians had the greatest preference for: (1) uniformly specifying the age group for which the drug is indicated in the INDICATIONS AND USAGE section, even for medical conditions that are highly associated with only one particular age group (e.g., adult patients), and (2) uniformly including administration information in relation to food (e.g., "with or without food") in the DOSAGE AND ADMINISTRATION section for drugs with oral dosing. The findings also suggest that including a long list of interacting drug examples in the DRUG INTERACTIONS section may be misinterpreted to be a comprehensive list. CONCLUSION This qualitative research suggests physicians may prefer more clarity in some sections of the PI.
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Affiliation(s)
| | | | | | - Janice Tzeng
- RTI International, Research Triangle Park, NC, USA
| | | | - Eric Brodsky
- US Food and Drug Administration, Silver Spring, MD, USA
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12
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Haque H, Alrowily A, Jalal Z, Tailor B, Efue V, Sarwar A, Paudyal V. Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using reason's accident causation theory. Int J Clin Pharm 2021; 43:1693-1704. [PMID: 34215959 PMCID: PMC8642372 DOI: 10.1007/s11096-021-01302-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/22/2021] [Indexed: 11/30/2022]
Abstract
Background Direct oral anticoagulants (DOACs) have revolutionised anticoagulant pharmacotherapy. However, DOAC-related medication incidents are known to be common. Objective To assess medication incidents associated with DOACs using an error theory and to analyse pharmacists’ contributions in minimising medication incidents in hospital in-patients. Setting A large University academic hospital in the West Midlands of England. Methods Medication incident data from the incident reporting system (48-months period) and pharmacists’ interventions data from the prescribing system (26-month period) relating to hospital in-patients were extracted. Reason’s Accident Causation Model was used to identify potential causality of the incidents. Pharmacists’ intervention data were thematically analysed. Main outcome measure (a) Frequency, type and potential causality of DOAC-related incidents; (b) nature of pharmacists’ interventions. Results A total of 812 reports were included in the study (124 medication incidents and 688 intervention reports). Missing drug/omission was the most common incident type (26.6%, n = 33) followed by wrong drug (16.1%, n = 20) and wrong dose/strength (11.3%, n = 14). A high majority (89.5%, n = 111) of medication incidents were caused by active failures. Patient discharge without anticoagulation supply and failure to restart DOACs post procedure/scan were commonly recurring themes. Pharmacists’ interventions most frequently related to changes in pharmacological strategy, including drug or dose changes (38.1%, n = 262). Impaired renal function was the most common reason for dose adjustments. Conclusion Prescribers’ active failure rather than system errors (i.e. latent failures) contributed to the majority of DOAC-related incidents. Reinforcement of guideline adherence, prescriber education, harnessing pharmacists’ roles and mandating renal function information in prescriptions are likely to improve patient safety.
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Affiliation(s)
- Hazera Haque
- School of Pharmacy, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Abdulrhman Alrowily
- School of Pharmacy, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Zahraa Jalal
- School of Pharmacy, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Bijal Tailor
- University Hospitals Birmingham NHS Foundations Trust, Birmingham, B15 2TH, UK
| | - Vicky Efue
- University Hospitals Birmingham NHS Foundations Trust, Birmingham, B15 2TH, UK
| | - Asif Sarwar
- University Hospitals Birmingham NHS Foundations Trust, Birmingham, B15 2TH, UK
| | - Vibhu Paudyal
- School of Pharmacy, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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Leviatan I, Oberman B, Zimlichman E, Stein GY. Associations of physicians' prescribing experience, work hours, and workload with prescription errors. J Am Med Inform Assoc 2021; 28:1074-1080. [PMID: 33120412 DOI: 10.1093/jamia/ocaa219] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/05/2020] [Accepted: 08/21/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We aimed to assess associations of physician's work overload, successive work shifts, and work experience with physicians' risk to err. MATERIALS AND METHODS This large-scale study included physicians who prescribed at least 100 systemic medications at Sheba Medical Center during 2012-2017 in all acute care departments, excluding intensive care units. Presumed medication errors were flagged by a high-accuracy computerized decision support system that uses machine-learning algorithms to detect potential medication prescription errors. Physicians' successive work shifts (first or only shift, second, and third shifts), workload (assessed by the number of prescriptions during a shift) and work-experience, as well as a novel measurement of physicians' prescribing experience with a specific drug, were assessed per prescription. The risk to err was determined for various work conditions. RESULTS 1 652 896 medical orders were prescribed by 1066 physicians; The system flagged 3738 (0.23%) prescriptions as erroneous. Physicians were 8.2 times more likely to err during high than normal-low workload shifts (5.19% vs 0.63%, P < .0001). Physicians on their third or second successive shift (compared to a first or single shift) were more likely to err (2.1%, 1.8%, and 0.88%, respectively, P < .001). Lack of experience in prescribing a specific medication was associated with higher error rate (0.37% for the first 5 prescriptions vs 0.13% after over 40, P < .001). DISCUSSION Longer hours and less experience in prescribing a specific medication increase risk of erroneous prescribing. CONCLUSION Restricting successive shifts, reducing workload, increasing training and supervision, and implementing smart clinical decision support systems may help reduce prescription errors.
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Affiliation(s)
- Ilona Leviatan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bernice Oberman
- Gertner Institute for Epidemiology and Health Policy Research, Tel HaShomer, Ramat Gan, Israel
| | - Eyal Zimlichman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Management Wing, Chaim Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
| | - Gideon Y Stein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Internal Medicine "A," Meir Medical Center, Clalit Health Services, Kfar Saba, Israel
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Lloyd M, Bennett N, Wilkinson A, Furlong N, Cardwell J, Michaels S. A mixed-methods evaluation of the impact of a pharmacist-led feedback pilot intervention on insulin prescribing in a hospital setting. Res Social Adm Pharm 2021; 17:2006-2014. [PMID: 33775557 DOI: 10.1016/j.sapharm.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
AIMS To explore the impact of a prescribing feedback intervention on insulin prescribing. METHODS This was a mixed-methods study in a hospital setting. An insulin prescribing feedback intervention was delivered verbally and in writing to twelve doctors. Insulin prescribing error frequency was compared to ten doctors who had not received the feedback intervention. Insulin prescribing was audited over four weeks at the start and end of the intervention period. Semi-structured interviews were conducted with participating doctors who had received feedback, and qualitative data analysed thematically to explore the impact of the intervention on their prescribing practice. RESULTS Prescribing data were collected on 370 insulin prescriptions with 241 errors identified. A significant reduction (χ2 = 22.6, p=<0.05) in insulin prescribing error frequency was observed in the intervention group, with a non-significant increase reported in the control group. Feedback was received positively and considered valuable by doctors, supporting development of their knowledge and skills and encouraging reflection on their prescribing performance. Doctors described enhanced confidence in insulin prescribing and a desire to improve as a prescriber and avoid harm, with feedback raising awareness of their development needs. Prescribers also described enhanced team work, with greater information and feedback seeking behavior to inform future prescribing decisions. CONCLUSIONS Feedback has potential to improve insulin prescribing and is a valued and acceptable process intervention for doctors. The impact on insulin prescribing practice is varied and complex influencing the capability, opportunity and motivation of prescribers to adapt and evolve their behavior in response to ongoing feedback.
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Affiliation(s)
- M Lloyd
- Clinical Education Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK.
| | - N Bennett
- Clinical Education Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - A Wilkinson
- Pharmacy Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - N Furlong
- Diabetes Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - J Cardwell
- Diabetes Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - S Michaels
- Diabetes Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
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Tran VD, Cao NTT, Le MH, Pham DT, Nguyen KT, Dorofeeva VV, Loskutova EE. Medical staff perspective on factors influencing their prescribing decisions: a cross-sectional study in Mekong Delta, Vietnam. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2021. [DOI: 10.1093/jphsr/rmaa011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objectives
Understanding medical staff’s prescription behaviors helps improve the quality of prescriptions and the rationality of medication use. Although factors affecting the prescribing decisions were discussed in various studies worldwide, limited knowledge of these issues has been reported in Vietnam. This paper aims to examine factors that influence prescribing behavior concerning medical staff’s demographics and characteristic differences.
Methods
Quantitative descriptive cross-sectional study, using adapted questionnaire consisting of 27 factors divided into 9 factor categories, was conducted with medical staff in Mekong Delta during June–July, 2019. Rasch analysis was performed to assess the questionnaire psychometric properties. Descriptive analysis, parametric tests and non-parametric tests were utilized to address the study objectives.
Key findings
A total of 201 participants completed the questionnaire. A majority of participants (>90%) agreed that their own decision to prescribe a drug was influenced by several factors such as drug safety and efficacy (92.5%), patient history (92.0%), patient income (92.0%) and patient disease status (91.0%). There were significant age differences in influences on prescribing decision. Medical staff aged under 30 appreciated the role of pharmacists higher than whose aged 31–40 (P-value = 0.010) and over 40 (P-value = 0.013). Additionally, they were more concerned with ‘patient characteristics’ including patient request, expectations, and disease status when making prescribing decisions compared with whose aged over 40 (P-value = 0.005).
Conclusions
The study revealed various factors influencing medical staff prescription decision-making processes. These findings could be useful for pharmaceutical companies in Vietnam in developing marketing strategies, and for policy-makers in timely improvement of prescription quality.
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Affiliation(s)
- Van De Tran
- Department of Traditional Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
- Department of Drug Administration, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
- Department of Pharmaceutical Management and Economics, Faculty of Medicine, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Nguyen Thi Tai Cao
- Department of Biology and Genetics, Faculty of Basic Sciences, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Minh Hoang Le
- Department of Traditional Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Duy Toan Pham
- Department of Chemistry, College of Natural Sciences, Can Tho University, Can Tho, Vietnam
| | - Kien Trung Nguyen
- Department of Physiology, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Valeria Valeryevna Dorofeeva
- Department of Pharmaceutical Management and Economics, Faculty of Medicine, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Ekaterina Efimovna Loskutova
- Department of Pharmaceutical Management and Economics, Faculty of Medicine, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
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16
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Abhary S, Botti M, Dhulia A, Tham C, Loh E, Catford J. Factors impacting health and well-being and the utilisation of supports among Australian doctors in medical specialty training. BMJ LEADER 2020. [DOI: 10.1136/leader-2020-000227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PurposeTo explore factors impacting the health and well-being of doctors undertaking various specialty training programs, and attitudes towards and utilisation of supports during their training. This is a subset of data from a larger study exploring experiences of doctors in Australian specialty training—a qualitative study of enablers, stressors and supports.MethodsIn this qualitative study, registrars in specialist training programmes in Australia were invited and interviewed between August 2015 and August 2016. Semistructured open-ended questions were used to explore topics of relevance to their workplace, training, support service utilisation and personal lives. Interviews were transcribed verbatim, deidentified and content and thematic analysis undertaken. Recruitment was ceased when data saturation was reached and no new themes emerged. Emerging key themes are reported in this studyResults17 participants were recruited (including 1 Indigenous and 1 international medical graduate). A total of six specialty training programmes, across multiple states at various locations across Australia, were represented.Common themes impacting health and well-being regarding workplace and training stressors were identified, including poor supervision, shiftwork and on-call, inability to take sick leave, bullying and harassment, college-related factors, examination preparation and work–life imbalance. Several of these were identified as having actual and perceived negative impacts on patient outcomes and safety.The majority of participants underused existing supports and were unaware of the breadth of support services available to them. Barriers to accessing these services included concerns about their confidentiality and career repercussions.ConclusionsThis first Australian pilot study highlighted many stressors and enablers in the workplace, training and personal lives of registrars. The underutilisation and barriers to access of support services were discovered. Several multisystem strategies are required and discussed in this report to address these complex issues identified as affecting the health and well-being of junior doctors.
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17
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Lloyd M, Watmough SD, O'Brien SV, Hardy K, Furlong N. Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting. Res Social Adm Pharm 2020; 17:1579-1587. [PMID: 33341404 DOI: 10.1016/j.sapharm.2020.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 11/19/2020] [Accepted: 12/13/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prescribing errors are prevalent in hospital settings with provision of feedback recommended to support prescribing of doctors. Feedback on prescribing has been described as feasible and valued but limited by doctors, with pharmacists described as credible facilitators of prescribing feedback. Evidence supporting prescribing feedback has been limited to date. A formalised programme of pharmacist-led prescribing error feedback was designed and implemented to support prescribers. OBJECTIVE To evaluate the impact of a prescribing feedback intervention on prescribing error rates and frequency of prescribing error severity and type. METHOD Prospective prescribing audits were undertaken across sixteen hospital wards in a UK teaching hospital over a five day period with 36 prescribers in the intervention group and 41 in the control group. The intervention group received pharmacist-led, individualised constructive feedback on their prescribing, whilst the control group continued with existing practice. Prescribing was re-audited after three months. Prescribing errors were classified by type and severity and data were analysed using relevant statistical tests. RESULTS A total of 5191 prescribed medications were audited at baseline and 5122 post-intervention. There was a mean prescribing error rate of 25.0% (SD 16.8, 95% CI 19.3 to 30.7) at baseline and 6.7% (SD 9.0, 95% CI 3.7 to 9.8) post-intervention for the intervention group, and 19.7% (SD 14.5, 95% CI 15.2 to 24.3) at baseline and 25.1% (SD 17.0, 95% CI 19.8 to 30.6) post-intervention for the control group with a significant overall change in prescribing error rates between groups of 23.7% (SD 3.5, 95% CI, -30.6 to -16.8), t(75) = -6.9, p < 0.05. The frequency of each error type and severity rating was reduced in the intervention group, whilst the error frequency of some error types and severity increased in the control group. CONCLUSION Pharmacist-led prescribing feedback has the potential to reduce prescribing errors and improve prescribing outcomes and patient safety.
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Affiliation(s)
- M Lloyd
- Clinical Education Department, St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK.
| | - S D Watmough
- School of Medicine, Faculty of Health and Social Care, Edge Hill University, Ormskirk, L39 4QP, UK
| | - S V O'Brien
- St. Helens CCG, St. Helens Chambers, St. Helens, Merseyside, WA10 1YF, UK
| | - K Hardy
- St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - N Furlong
- St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
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18
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Alshahrani F, Marriott JF, Cox AR. A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Int J Clin Pharm 2020; 43:884-892. [PMID: 33165835 PMCID: PMC8352824 DOI: 10.1007/s11096-020-01192-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/29/2020] [Indexed: 11/16/2022]
Abstract
Background Computerised Physician Order Entry (CPOE) is considered to enhance the safety of prescribing. However, it can have unintended consequences and new forms of prescribing error have been reported. Objective The aim of this study was to explore the causes and contributing factors associated with prescribing errors reported by multidisciplinary prescribers working within a CPOE system. Main Outcome Measure Multidisciplinary prescribers experience of prescribing errors in an CPOE system. Method This qualitative study was conducted in a hospital with a well-established CPOE system. Semi-structured qualitative interviews were conducted with prescribers from the professions of pharmacy, nursing, and medicine. Interviews analysed using a mixed inductive and deductive approach to develop a framework for the causes of error. Results Twenty-three prescribers were interviewed. Six main themes influencing prescribing were found: the system, the prescriber, the patient, the team, the task of prescribing and the work environment. Prominent issues related to CPOE included, incorrect drug name picking, default auto-population of dosages, alert fatigue and remote prescribing. These interacted within a complex prescribing environment. No substantial differences in the experience of CPOE were found between the professions. Conclusion Medical and non-medical prescribers have similar experiences of prescribing errors when using CPOE, aligned with existing published literature about medical prescribing. Causes of electronic prescribing errors are multifactorial in nature and prescribers describe how factors interact to create the conditions errors. While interventions should focus on direct CPOE issues, such as training and design, socio-technical, and environmental aspects of practice remain important.
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Affiliation(s)
- Fahad Alshahrani
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Security Forces Hospital, Riyadh, Saudi Arabia
| | - John F Marriott
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Anthony R Cox
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Factors Affecting Prescriber Implementation of Computer-Generated Medication Recommendations in the SENATOR Trial: A Qualitative Study. Drugs Aging 2020; 37:703-713. [DOI: 10.1007/s40266-020-00787-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Coughlan JJ, Mullins CF, Kiernan TJ. Diagnosing, fast and slow. Postgrad Med J 2020; 97:103-109. [PMID: 32595113 DOI: 10.1136/postgradmedj-2019-137412] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/10/2020] [Accepted: 06/01/2020] [Indexed: 11/04/2022]
Abstract
Diagnostic error is increasingly recognised as a source of significant morbidity and mortality in medicine. In this article, we will attempt to address several questions relating to clinical decision making; How do we decide on a diagnosis? Why do we so often get it wrong? Can we improve our critical faculties?We begin by describing a clinical vignette in which a medical error occurred and resulted in an adverse outcome for a patient. This case leads us to the concepts of heuristic thinking and cognitive bias. We then discuss how this is relevant to our current clinical paradigm, examples of heuristic thinking and potential mechanisms to mitigate bias.The aim of this article is to increase awareness of the role that cognitive bias and heuristic thinking play in medical decision making. We hope to motivate clinicians to reflect on their own patterns of thinking with an overall aim of improving patient care.
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Affiliation(s)
- J J Coughlan
- Cardiology, Saint James's Hospital, Dublin, Ireland
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21
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Chhabra A, Nidhi C, Jain A. Knowledge, attitudes and practice preference regarding drug prescriptions of resident dental doctors: A quantitative study. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2020; 30:91-100. [PMID: 31256074 DOI: 10.3233/jrs-180021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There has been an increasing need to examine undergraduate dental education in prescribing to confirm whether it is establishing the goal of producing safe and rational prescribers. Prescribing by dental doctors after graduation is influenced by a variety of factors: the different teaching approaches of the professors at the clinics and in the pharmacology course, fellow colleagues and even the information provided by the pharmaceutical industry. OBJECTIVE The aim of this study was to assess the prescription knowledge, attitude, preference and common errors made by junior resident dental doctors in the dental department of two medical colleges and hospitals in India. METHODS Dental graduates (n = 70) who served as junior resident doctors at dental departments and graduated from various dental colleges in India, participated in the study. A survey was conducted among 70 junior resident dental doctors in the dental department, applying a previously validated questionnaire consisting of open-ended questions. The knowledge, attitude and practice preference of resident doctors regarding drug prescription and common errors made by them were analyzed and reviewed. RESULTS The most frequent response to each question was considered the most significant. The most common reason for prescribing medication was infection (n = 33, 47.14%) and the most widely prescribed antibiotic was amoxicillin (n = 29, 41.42%). The most frequent error reported by resident doctors was lack of knowledge about drug posology (n = 31, 44.28%). Maximum number of junior doctors acquired the information for prescribing drugs from their faculty (n = 33, 47.14%). Around 45.71% dental doctors had no knowledge about the WHO Guide to Good Prescribing. About 50- 60% doctors had knowledge about the dose, frequency, duration and route of administration of the drug prescribed. While prescribing drugs to the patient, 25.71% doctors explain the disease and treatment properly to the patient; 24.28% doctors do not criticize other doctors, and 10% doctors address the patient by name. CONCLUSION The results of this study indicate that resident dental doctors' knowledge, attitudes and behavior about the drug prescription need to be improved. More studies are needed to determine whether this issue affects the quality of patient care and the effectiveness and safety of treatments.
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Affiliation(s)
- Anuj Chhabra
- Department of Dental Surgery, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India
| | - C Nidhi
- Department of Dental Surgery, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India
| | - Anurag Jain
- Department of Dental Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Lee C, McCrory R, Tully MP, Carrington A, Donnelly R, Dornan T. Readiness to prescribe: Using educational design to untie the Gordian Knot. PLoS One 2020; 15:e0227865. [PMID: 31978199 PMCID: PMC6980548 DOI: 10.1371/journal.pone.0227865] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 12/31/2019] [Indexed: 11/27/2022] Open
Abstract
Introduction Junior residents routinely prescribe medications for hospitalised patients with only arms-length supervision, which compromises patient safety. A cardinal example is insulin prescribing, which is commonplace, routinely delegated to very junior doctors, difficult, potentially very dangerous, and getting no better. Our aim was to operationalise the concept of ‘readiness to prescribe’ by validating an instrument to quality-improve residents’ workplace prescribing education. Methods Guided by theories of behaviour change, implementation, and error, and by empirical evidence, we developed and refined a mixed-methods 24-item evaluation instrument, and analysed numerical responses from Foundation Trainees (junior residents) in Northern Ireland, UK using principal axis factoring, and conducted a framework analysis of participants’ free-text responses. Results 255 trainees participated, 54% women and 46% men, 80% of whom were in the second foundation year. The analysis converged on a 4-factor solution explaining 57% of the variance. Participants rated their capability to prescribe higher (79%) than their capability to learn to prescribe (69%; p<0.001) and rated the support to their prescribing education lower still (43%; p<0.001). The findings were similar in men and women, first and second year trainees, and in different hospitals. Free text responses described an unreflective type of learning from experience in which participants tended to 'get by' when faced with complex problems. Discussion Operationalising readiness to prescribe as a duality, comprising residents’ capability and the fitness of their educational environments, demonstrated room for improvement in both. We offer the instrument to help clinical educators improve the two in tandem.
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Affiliation(s)
- Ciara Lee
- Centre for Medical Education, Queen’s University Belfast, Belfast, United Kingdom
| | - Richard McCrory
- Centre for Medical Education, Queen’s University Belfast, Belfast, United Kingdom
| | - Mary P. Tully
- Division of Pharmacy and Optometry, University of Manchester, Manchester, United Kingdom
| | | | - Rosie Donnelly
- South-Eastern Health and Social Care Trust, Belfast, United Kingdom
| | - Tim Dornan
- Centre for Medical Education, Queen’s University Belfast, Belfast, United Kingdom
- * E-mail:
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Sutherland A, Phipps DL, Tomlin S, Ashcroft DM. Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review. BMC Pediatr 2019; 19:486. [PMID: 31829142 PMCID: PMC6905106 DOI: 10.1186/s12887-019-1875-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Problems arising from medicines usage are recognised as a key patient safety issue. Children are a particular concern, given that they are more likely than adults to experience medication-related harm. While previous reviews have provided an estimate of prevalence in this population, these predate recent developments in the delivery of paediatric care. Hence, there is a need for an updated, focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK, in order to support the development and targeting of interventions to improve medication safety. METHODS Nine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to April 2019. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted. RESULTS In all, 26 studies were included. There were no studies which specifically reported prevalence of adverse drug events. Two adverse drug reaction studies reported a median prevalence of 25.6% of patients (IQR 21.8-29.9); 79.2% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors (median prevalence 6.5%; IQR 4.7-13.3); of which, the median rate of dose prescribing errors was 11.1% (IQR 2.9-13). Ten studies reported on administration errors with a median prevalence of 16.3% (IQR 6.4-23). Administration technique errors represented 53% (IQR 52.7-67.4) of these errors. Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 23% (Range 20.1-46) of prescribed medication; 70.3% (Range 50-78) were classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors. CONCLUSIONS Children are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm,, there is a need for a deeper theoretical understanding of paediatric medication systems to enable more effective interventions to be developed to improve patient safety.
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Affiliation(s)
- Adam Sutherland
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT UK
- Pharmacy Department, Royal Manchester Children’s Hospital, Manchester Universities NHS Foundation Trust, Oxford Road, Manchester, M13 9WL UK
| | - Denham L. Phipps
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL UK
| | - Stephen Tomlin
- Pharmacy Department, Great Ormond Street Hospital, Holborn, London, WC1N 3JH UK
| | - Darren M. Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL UK
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Zamani M, Hall K, Cunningham A, Chin N, Kent‐Ferguson S, Wadhwa V. Effectiveness of ‘do not disturb’ strategies in reducing errors during discharge prescription writing. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Mazdak Zamani
- Department of Pharmacy Maroondah Hospital Eastern Health Melbourne Australia
| | - Kylie Hall
- General Medicine Stream Maroondah Hospital Eastern Health Melbourne Australia
| | - Amanda Cunningham
- General Medicine Stream Maroondah Hospital Eastern Health Melbourne Australia
| | - Nicholas Chin
- Department of Medicine Maroondah Hospital Eastern Health Melbourne Australia
| | - Sally Kent‐Ferguson
- Department of Post Graduate Medical Education Eastern Health Melbourne Australia
| | - Vikas Wadhwa
- Department of Medicine Maroondah Hospital Eastern Health Melbourne Australia
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Parker H, Farrell O, Bethune R, Hodgetts A, Mattick K. Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation. Br J Clin Pharmacol 2019; 85:2405-2413. [PMID: 31313340 PMCID: PMC6783579 DOI: 10.1111/bcp.14065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/19/2019] [Accepted: 07/01/2019] [Indexed: 11/29/2022] Open
Abstract
Aims To develop and evaluate a feasible, authentic pharmacist‐led prescribing feedback intervention for doctors‐in‐training, to reduce prescribing errors. Methods This was a mixed methods study. Sixteen postgraduate doctors‐in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi‐structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically. Results During the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P < .0001). Pharmacist‐led video‐stimulated prescribing feedback was feasible and positively received by participants, who appreciated the reinforcement of good practice as well as the opportunity to reflect on and improve practice. Conclusions Feedback to doctors‐in‐training tends to be infrequent and often negative, but this feasible feedback strategy significantly reduced prescribing errors and was well received by the target audience as a supportive developmental approach.
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Affiliation(s)
- Hazel Parker
- Pharmacy Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Odran Farrell
- Pharmacy Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Bethune
- Exeter Surgical Health Service Research Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Ali Hodgetts
- Pharmacy Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Karen Mattick
- University of Exeter Medical School, University of Exeter, Exeter, UK
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Druedahl LC, Mølby Hansen J, Freese EL, Almarsdóttir AB, Traulsen JM. Mandatory medication content in the curricula of six health care personnel types with patient contact in Denmark. Basic Clin Pharmacol Toxicol 2019; 124:431-438. [PMID: 30311428 DOI: 10.1111/bcpt.13147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/05/2018] [Indexed: 11/30/2022]
Abstract
Medication use is a complex process involving different types of health care personnel. This study investigated and compared mandatory medication content in the curricula of six types of health care personnel with patient contact. Using content analysis, three independent raters analysed the mandatory medication content for physicians, pharmacists, pharmaconomists, nurses, health care assistants and support workers in the Capital Region of Denmark. Three dimensions were analysed as follows: communication with patients about medication, medication use or pharmacology and medication formulation and production. ECTS credits were totalled for courses analysed to have high or medium content, and inter-rater reliability was tested with Fleiss' kappa. The total mandatory medication content for pharmacists was 197.0 ECTS, physicians 136.0 ECTS, pharmaconomists 123.3 ECTS, nurses 52.0 ECTS, health care assistants 17.8 ECTS and support workers 0.0 ECTS. Communication with patients about medication was included to the greatest extent in the educations of pharmaconomists (112.0 ECTS), pharmacists (37.5 ECTS) and physicians (25.0 ECTS). Knowledge about medication use and pharmacology was taught primarily to pharmacists (146.5 ECTS), physicians (123.6 ECTS) and pharmaconomists (89.8 ECTS) and to a lesser extent nurses (52.0 ECTS), health care assistants (17.8 ECTS) and support workers (0.0 ECTS). Medication formulation and production were taught only to pharmacists (93.0 ECTS) and pharmaconomists (25.1 ECTS). Mapping the basic competencies about medication taught to each of the six health care personnel types can lead to a better understanding of how they can complement each other in patient care. The study points to weaknesses in medication curriculum content for health care personnel with the most patient contact.
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Affiliation(s)
- Louise C Druedahl
- Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Johanne Mølby Hansen
- Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Anna Birna Almarsdóttir
- Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Janine M Traulsen
- Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Lewis PJ, Seston E, Tully MP. Foundation year one and year two doctors' prescribing errors: a comparison of their causes. Postgrad Med J 2019; 94:634-640. [PMID: 30635431 DOI: 10.1136/postgradmedj-2018-135816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/10/2018] [Accepted: 11/10/2018] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Penny J Lewis
- Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
| | - Elizabeth Seston
- Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
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Alanazi MA, Tully MP, Lewis PJ. Prescribing errors by junior doctors- A comparison of errors with high risk medicines and non-high risk medicines. PLoS One 2019; 14:e0211270. [PMID: 30703104 PMCID: PMC6355202 DOI: 10.1371/journal.pone.0211270] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 01/10/2019] [Indexed: 11/18/2022] Open
Abstract
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'.
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Affiliation(s)
- Mahdi A. Alanazi
- Division of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Mary P. Tully
- Division of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Penny J. Lewis
- Division of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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Farag S. A response to the perception of the severity of medical error and the level of clinical seniority. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2018; 9:823-824. [PMID: 30519139 PMCID: PMC6235157 DOI: 10.2147/amep.s178072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Soma Farag
- Medical Department at Imperial College, London University, London, UK,
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Keers RN, Plácido M, Bennett K, Clayton K, Brown P, Ashcroft DM. What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PLoS One 2018; 13:e0206233. [PMID: 30365509 PMCID: PMC6203370 DOI: 10.1371/journal.pone.0206233] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/09/2018] [Indexed: 11/19/2022] Open
Abstract
Objective Medication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England. Methods Registered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants’ experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason’s model of accident causation. Results A total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication. Conclusions To our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent ‘system’ failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational ‘systems’ failures to reduce error.
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Affiliation(s)
- Richard N. Keers
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, United Kingdom
- NIHR Greater Manchester Patient Safety Translational Research Centre, MAHSC, University of Manchester, Manchester, United Kingdom
- Medicines Management Team, Greater Manchester Mental Health NHS Foundation Trust, Park House Hospital, North Manchester General Hospital, Manchester, United Kingdom
- * E-mail:
| | - Madalena Plácido
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, United Kingdom
| | - Karen Bennett
- Medicines Management Team, Greater Manchester Mental Health NHS Foundation Trust, Park House Hospital, North Manchester General Hospital, Manchester, United Kingdom
- School of Health and Human Sciences, University of Bolton, Bolton, United Kingdom
| | - Kristen Clayton
- Medicines Management Team, Greater Manchester Mental Health NHS Foundation Trust, Park House Hospital, North Manchester General Hospital, Manchester, United Kingdom
| | - Petra Brown
- Medicines Management Team, Greater Manchester Mental Health NHS Foundation Trust, Park House Hospital, North Manchester General Hospital, Manchester, United Kingdom
| | - Darren M. Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, United Kingdom
- NIHR Greater Manchester Patient Safety Translational Research Centre, MAHSC, University of Manchester, Manchester, United Kingdom
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Russ SJ, Morrison I, Bell C, Morse JC, Mackenzie RK, Johnston MK. Relationship between acute stress and clinical performance in medical students: a pilot simulation study. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2018; 4:171-178. [DOI: 10.1136/bmjstel-2017-000276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/08/2017] [Accepted: 01/20/2018] [Indexed: 11/03/2022]
Abstract
BackgroundAcute 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.AimIn 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.MethodsSecond-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.ResultsFifty 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.ConclusionsThis 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.
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Understanding the causes of prescribing errors from a behavioural perspective. Res Social Adm Pharm 2018; 15:546-557. [PMID: 30041915 DOI: 10.1016/j.sapharm.2018.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 07/02/2018] [Accepted: 07/08/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION While many attempts have been made to reduce prescribing errors (PEs), they persist. PE is not in itself a behaviour, but a consequence of a prescribing behaviour. Interventions aimed at prescribers should focus on understanding prescribers' behaviours. OBJECTIVES The aim of this study was to use the capability, opportunity, motivation - behaviour (COM-B) model to explore the behaviours that could have caused PEs made by senior doctors in a speciality paediatric inpatient ward. METHODS A qualitative approach was used to investigate prescribers' behaviours in a 26-bed paediatric oncology ward. Error data were collected over a two-month period and were presented during focus groups with prescribers, which were audio-recorded and transcribed verbatim. Thematic analysis was used to identify contributory factors to errors, which was used to identify sources of behaviours using the COM-B model. RESULTS Behaviours related to prescribers' capabilities were: prescribers' improper use of the software because of insufficient skills, and prescribers' inability to prescribe correctly because of lack of knowledge. Behaviours related to opportunities in the environment were: prescribers' inability to make an informed decision because of poor access to patient information, inability to properly complete a task because of heavy workload and interruption, and having to re-check doses frequently because of frequent change in patients' weight and surface area. Those related to motivation were: prescribers unquestioningly following recommendations and not communicating with other specialists because they over-trusted them or feared a negative reaction, and prescribers inability to complete a task because of other competing and preferable tasks at the same time. CONCLUSION Employing COM-B helped in identifying causes of PEs from a new perspective. Future work could focus on mapping identified sources of behaviour and errors against appropriate intervention functions and policies in order to design more successful interventions.
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Jones CE, Phipps DL, Ashcroft DM. Understanding procedural violations using Safety-I and Safety-II: The case of community pharmacies. SAFETY SCIENCE 2018; 105:114-120. [PMID: 29861550 PMCID: PMC5862557 DOI: 10.1016/j.ssci.2018.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 01/05/2018] [Accepted: 02/02/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Procedural violations are known to occur in a range of work settings, and are an important topic of interest with regard to safety management. A Safety-I perspective sees violations as undesirable digressions from standardised procedures, while a Safety-II perspective sees violations as adaptations to a complex work system. This study aimed to apply both perspectives to the examination of violations in community pharmacies. DESIGN Twenty-four participants (13 pharmacists and 11 pharmacy support staff) were purposively sampled to participate in semi-structured interviews using the critical incident technique. Participants described violations they made during the course of their work. Interviews were digitally recorded, transcribed verbatim and analysed using template analysis. SETTING Community pharmacies located in England and Wales. RESULTS 31 procedural violations were described during the interviews revealing multiple reasons for violations in this setting. Our findings suggest that from a Safety-II perspective, staff violated to adapt to situations and to manage safety. However, participants also violated procedures in order to maintain productivity which was found to increase risk in some, but not all situations. Procedural violations often relied on the context in which staff were working, resulting in the violation being deemed rational to the individual making the violation, yet the behaviour may be difficult to justify from an outside perspective. CONCLUSIONS Combining Safety-I and Safety-II perspectives provided a detailed understanding of the underlying reasons for procedural violations. Our findings identify aspects of practice that could benefit from targeted interventions to help support staff in providing safe patient care.
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Affiliation(s)
- Christian E.L. Jones
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, United Kingdom
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, United Kingdom
| | - Denham L. Phipps
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, United Kingdom
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, United Kingdom
| | - Darren M. Ashcroft
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, United Kingdom
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, United Kingdom
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Hamel C, Tortolano L, Bermudez E, Desmaris R, Klein S, Slimano F, Lemare F. Computerized pediatric oncology prescriptions review by pharmacist: A descriptive analysis and associated risk factors. Pediatr Blood Cancer 2018; 65. [PMID: 29251399 DOI: 10.1002/pbc.26897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/23/2017] [Accepted: 10/23/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND Systematic prescription analyses by clinical pharmacists result in pharmacist interventions (PIs) to reduce prescription errors and improve medication safety. PIs are particularly critical in oncology, because antineoplastic drugs are highly toxic with low therapeutic indexes especially in a pediatric population. The aim of this study is to describe PIs in a pediatric oncology department and to identify potential risk factors associated with prescription errors. PROCEDURE We conducted a 20-month observational study in a pediatric oncology department concerning electronic prescription of injectable chemotherapies was conducted. PIs were analyzed for drug-related problems (DRPs), type of intervention, population characteristics, involved drugs, and the potential risk factors. RESULTS Clinical pharmacists made 90 PIs for 10,214 antineoplastic prescriptions for a rate of 88 PIs per 10,000 prescriptions. The majority of DRPs were dosage errors (61.8%), imputable to measurements (weight and/or height) in 47.4% or unreported dose reduction. The most common patient ages were in the range 1-10 years and the most common time for medical double checks was 2-9 pm. There were statistically more prescription errors in standardized protocols (P < 0.001). CONCLUSIONS Not surprisingly, PIs were predominantly to correct dose errors, half of which related to height and weight measurements that were not updated. No significant risk factors for errors were identified for errors except in the standardized status of prescription, which appears to be linked in part to our software that did not automatically reflect dose reduction from one course to the next. Medical double-checking followed by a clinical pharmacist's double check were effective in order to prevent prescription errors.
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Affiliation(s)
- Claire Hamel
- Department of Clinical Pharmacy, Gustave Roussy Cancer Campus, Villejuif Cedex, 94805, France
| | - Lionel Tortolano
- Department of Clinical Pharmacy, Gustave Roussy Cancer Campus, Villejuif Cedex, 94805, France.,EA401, IFR141, Faculty of Pharmacy, Paris-sud, University, Chatenay-Malabry, 92296, France.,Assistance Publique-Höpitaux de Paris, Groupe hospitalier Henri Mondor, Department of Pharmacy, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, F-94010, France
| | - Elisabeth Bermudez
- Department of Clinical Pharmacy, Gustave Roussy Cancer Campus, Villejuif Cedex, 94805, France
| | - Romain Desmaris
- Department of Clinical Pharmacy, Gustave Roussy Cancer Campus, Villejuif Cedex, 94805, France
| | - Sébastien Klein
- Department of Pediatric Oncology, Gustave Roussy Cancer Campus, Villejuif Cedex, 94805, France
| | - Florian Slimano
- Department of Clinical Pharmacy, Gustave Roussy Cancer Campus, Villejuif Cedex, 94805, France.,MEDyC Research Unit, UMR CNRS/URCA no. 7369, Reims University, Reims, 51100, France.,Facuty of Pharmacy, Reims University, Reims, 51100, France
| | - François Lemare
- Department of Clinical Pharmacy, Gustave Roussy Cancer Campus, Villejuif Cedex, 94805, France.,Chair of Clinical Pharmacy, Faculty of Pharmacy of Paris, Sorbonne-Paris University, Paris, 75 270, France.,EA 7348 MOS, Ecole des Hautes Etudes en Santé Publique, Rennes, 35043, France
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Lewis PJ, Forster A, Magowan M, Armstrong D. Exploring the experiences and opinions of hospital pharmacists working 24/7 shifts. Eur J Hosp Pharm 2018; 26:253-257. [PMID: 31656611 DOI: 10.1136/ejhpharm-2017-001401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 11/03/2022] Open
Abstract
Objectives The expansion of out-of-hours pharmacy services results from a drive to improve patient care and promote integration into the wider healthcare team. However, there has been little attempt to explore these intended outcomes as well as the potential problems arising from working out of hours. The aim of this study was to explore the experiences and views of pharmacists who work shifts as part of a 24/7 pharmacy service. Methods Semistructured interviews with shift-working pharmacists were conducted. Data were analysed using a framework approach. Results Pharmacists described the positive impact they had on patient safety by ensuring the prompt supply of time-critical medicines and their proactive role in preventing adverse drug events. Pharmacists' on-site presence and attendance at handover promoted integration into the wider team and facilitated unplanned interventions. However, requests for non-urgent supplies were a source of frustration. Disparity of pharmacists' perceptions of senior support demonstrated a need to explore communication further and the importance of non-technical skills, such as communication in service provision. Shift work appeared to be a double-edged sword for work-life balance, preventing participation in regular hobbies, but providing flexibility. Service improvements could include technician support, greater feedback provision and improved ordering processes. Conclusions Overall, pharmacists believed the shift service exhibited numerous advantages over a traditional remote on-call service, particularly in improving aspects of patient safety and integration into the wider healthcare team. Clarity of the service scope and development of non-technical skills are areas for improvement and development.
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Affiliation(s)
- Penny J Lewis
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,Pharmacy Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Abbey Forster
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Matthew Magowan
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Debra Armstrong
- Pharmacy Department, Manchester University NHS Foundation Trust, Manchester, UK
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Axon DR, Lim RHM, Lewis PJ, Sandher S, Thondee J, Edwards K, Howard RL. Junior doctors' communication with hospital pharmacists about prescribing: findings from a qualitative interview study. Eur J Hosp Pharm 2018; 25:257-261. [PMID: 31157036 DOI: 10.1136/ejhpharm-2017-001449] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/14/2018] [Accepted: 01/16/2018] [Indexed: 11/03/2022] Open
Abstract
Objectives To explore factors affecting communication between Foundation Year (FY) 1 doctors and hospital pharmacists about prescribing from the junior doctors' perspective. Methods Trained interviewers (n=4) conducted semistructured interviews with FY1 doctors who were purposively sampled from three hospitals in England. FY1 doctors were asked about their experiences of communication with hospital pharmacists about their prescribing; instances where they disagreed with or did not implement a hospital pharmacist's recommendation; and their preferences for communicating with hospital pharmacists about prescribing. Interviews were audiorecorded, transcribed verbatim and analysed thematically. Results A total of 27 FY1 doctors were interviewed. Findings were categorised into four main themes: (1) nature and context of communication; (2) FY1 doctors' perceptions of communication with hospital pharmacists; (3) factors influencing FY1 doctors' decision whether to act on pharmacists' prescribing recommendations; and (4) suggestions to improve communication with pharmacists. FY1 doctors and hospital pharmacists generally communicated well. FY1 doctors appreciated and frequently acted on pharmacists' advice yet there was deference to senior medical staff when advice differed. Joint ward rounds, pharmacist-led teaching sessions and a standardised approach to communication were all suggested as ways to improve communication and may increase the likelihood of pharmacists' recommendations being acted on. Conclusions FY1 doctors and hospital pharmacists communicated frequently about medication prescribing. Issues occurred when there were differences in professional judgement between senior medical staff and pharmacists but these were usually resolved satisfactorily for the FY1 doctor. Further interventions to improve communication and safe prescribing could involve a multidisciplinary and systems approach.
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Affiliation(s)
- David Rhys Axon
- Department of Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, Arizona, USA
| | | | - Penny J Lewis
- Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Sarena Sandher
- Reading School of Pharmacy, University of Reading, Reading, UK
| | - Jenna Thondee
- Reading School of Pharmacy, University of Reading, Reading, UK
| | | | - Rachel L Howard
- Reading School of Pharmacy, University of Reading, Reading, UK
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06100] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundInterventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.ObjectivesThis study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.DesignThe review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.SettingPrimary and secondary care.ParticipantsNot applicable.InterventionsStudies related to antimicrobial prescribing for doctors in training.Main outcome measuresNot applicable.Data sourcesEMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.Review methodsClearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.ResultsA total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.LimitationsMost articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.ConclusionsThis review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.Future workMore work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.Study registrationThis study is registered as PROSPERO CRD42015017802.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Mark Pearson
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Simon Briscoe
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Brinkman DJ, Tichelaar J, Graaf S, Otten RHJ, Richir MC, van Agtmael MA. Do final-year medical students have sufficient prescribing competencies? A systematic literature review. Br J Clin Pharmacol 2018; 84:615-635. [PMID: 29315721 PMCID: PMC5867102 DOI: 10.1111/bcp.13491] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/19/2017] [Accepted: 11/26/2017] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- David J Brinkman
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research and Expertise Center in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jelle Tichelaar
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research and Expertise Center in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Sanne Graaf
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - René H J Otten
- Medical Library, Vrije Universiteit, Amsterdam, De Boelelaan 1105, 1081 HV, Amsterdam, The Netherlands
| | - Milan C Richir
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research and Expertise Center in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research and Expertise Center in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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39
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Abuzour AS, Lewis PJ, Tully MP. Practice makes perfect: A systematic review of the expertise development of pharmacist and nurse independent prescribers in the United Kingdom. Res Social Adm Pharm 2018; 14:6-17. [DOI: 10.1016/j.sapharm.2017.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 02/03/2017] [Accepted: 02/04/2017] [Indexed: 10/20/2022]
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40
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McCrory RFR, Gormley GJ, Maxwell AP, Dornan T. Learning to prescribe intravenous fluids: A scoping review. PERSPECTIVES ON MEDICAL EDUCATION 2017; 6:369-379. [PMID: 29119469 PMCID: PMC5732109 DOI: 10.1007/s40037-017-0386-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
INTRODUCTION Prescribing intravenous (IV) fluid therapy is a core skill expected of qualified doctors at the point of graduation, but medical graduates often feel ill-equipped to perform this task. This lack of preparedness contributes to treatment-related patient harm. This scoping review maps the current state of published evidence about how junior doctors prescribe IV fluid therapy and learn how to do it. METHODS We searched five electronic databases and grey literature from 1994 until June 2016 for articles describing any aspect of IV fluid prescribing practice or its education. A total of 63 articles were selected for analysis. Using the WHO Guide to Good Prescribing to categorize the extracted findings, our review focuses on prescribing IV fluids in adult generalist settings. RESULTS Most articles studied IV fluid prescribing from the perspective of the doctor. Junior clinicians struggled to conceptualize IV fluid prescribing as a 'whole task' in authentic work settings and lacked support. Educational interventions to improve IV fluid prescribing often focused on enhancing prescriber knowledge about fluid and electrolyte balance rather than execution of the prescribing task. CONCLUSIONS Our understanding of IV fluid prescribing as a holistic integrated skill is patchy, as is its performance. Current IV fluid prescribing education appears insufficient to foster safe and effective practice. For education to achieve the ultimate goal of safer prescribing in workplaces, we need a clearer understanding of how healthcare professionals prescribe IV fluids in real world practice.
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Affiliation(s)
- Richard F R McCrory
- Centre for Medical Education, Queens University Belfast, Belfast, Northern Ireland, UK.
- Regional Nephrology Unit, Belfast City Hospital, Belfast, Northern Ireland, UK.
| | - Gerard Joseph Gormley
- Centre for Medical Education, Queens University Belfast, Belfast, Northern Ireland, UK
| | | | - Tim Dornan
- Centre for Medical Education, Queens University Belfast, Belfast, Northern Ireland, UK
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41
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Lloyd M, Watmough SD, O'Brien SV, Furlong N, Hardy K. Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospital setting. Res Social Adm Pharm 2017; 14:936-943. [PMID: 29174646 DOI: 10.1016/j.sapharm.2017.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 10/21/2017] [Accepted: 11/16/2017] [Indexed: 11/18/2022]
Affiliation(s)
- M Lloyd
- St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK.
| | - S D Watmough
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, L39 4QP, UK
| | - S V O'Brien
- St. Helens CCG, St. Helens Chambers, St. Helens, Merseyside, WA10 1YF, UK
| | - N Furlong
- St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
| | - K Hardy
- St. Helens and Knowsley Hospitals NHS Trust, Whiston, Merseyside, L35 5DR, UK
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42
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Clarke N, Crowe S, Humphries N, Conroy R, O’Hare S, Kavanagh P, Brugha R. Factors influencing trainee doctor emigration in a high income country: a mixed methods study. HUMAN RESOURCES FOR HEALTH 2017; 15:66. [PMID: 28942731 PMCID: PMC5611654 DOI: 10.1186/s12960-017-0239-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 09/05/2017] [Indexed: 05/05/2023]
Abstract
BACKGROUND The Global Code of Practice on the International Recruitment of Health Personnel focuses particularly on migration of doctors from low- and middle-income countries. Less is understood about migration from high-income countries. Recession has impacted several European countries in recent years, and in some cases emigration has reached unprecedented levels. This study measures and explores the predictors of trainee doctor emigration from Ireland. METHODS Using a partially mixed sequential dominant (quantitative) study design, a nationally representative sample of 893 trainee doctors was invited to complete an online survey. Of the 523 who responded (58.6% response rate), 423 were still in Ireland and responded to questions on factors influencing intention to practice medicine abroad and are the subjects of this study. Explanatory factors for intention to practice medicine in Ireland in the foreseeable future, the primary outcome, included demographic variables and experiences of working within the Irish health system. Associations were examined using univariable and multivariable logistic regression to estimate odds ratios for factors influencing the primary outcome. Qualitative interviews were conducted with 50 trainee doctors and analysed thematically, exploring issues associated with intention to practice medicine abroad. RESULTS There were high levels of dissatisfaction among trainee doctors around working conditions, training and career progression opportunities in Ireland. However, most factors did not discriminate between intention to leave or stay. Factors that did predict intention to leave included dissatisfaction with one's work-life balance (odds ratio (OR) 2.51; 95% confidence interval (CI) 1.53-4.10; P < 0.001); feeling that the quality of training in Ireland was poor (OR 1.82; 95% CI 1.09-3.05; P = 0.002) and leaving for family or personal reasons (OR 1.85; 95% CI 1.08-3.17; P = 0.027). Qualitative findings illustrated the stress of doing postgraduate training with inadequate supervision, lack of ring-fenced training time and pressures on personal and family life. CONCLUSIONS Large-scale dissatisfaction with working, training and career opportunities point to systemic factors that need to be addressed by health workforce planners if Ireland is to retain and benefit from a motivated medical workforce, given trainees' perceptions that there are better opportunities abroad.
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Affiliation(s)
- Nicholas Clarke
- Department of Epidemiology and Public Health Medicine, RCSI, Beaux Lane House, Mercer Street, Dublin 2, Ireland
| | - Sophie Crowe
- Department of Epidemiology and Public Health Medicine, RCSI, Beaux Lane House, Mercer Street, Dublin 2, Ireland
| | - Niamh Humphries
- Department of Epidemiology and Public Health Medicine, RCSI, Beaux Lane House, Mercer Street, Dublin 2, Ireland
- Royal College of Physicians of Ireland, Dublin, Ireland
| | - Ronan Conroy
- Department of Epidemiology and Public Health Medicine, RCSI, Beaux Lane House, Mercer Street, Dublin 2, Ireland
| | | | | | - Ruairi Brugha
- Department of Epidemiology and Public Health Medicine, RCSI, Beaux Lane House, Mercer Street, Dublin 2, Ireland
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review. J Antimicrob Chemother 2017; 72:2418-2430. [PMID: 28859445 PMCID: PMC5890780 DOI: 10.1093/jac/dkx194] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/20/2017] [Accepted: 05/22/2017] [Indexed: 12/14/2022] Open
Abstract
Background Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Mark Pearson
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Peninsula Schools of Medicine & Dentistry, Plymouth University, Drake Circus Plymouth, Devon PL4 8AA, UK
| | - Simon Briscoe
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
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Keyworth C, Hart J, Thoong H, Ferguson J, Tully M. A Technological Innovation to Reduce Prescribing Errors Based on Implementation Intentions: The Acceptability and Feasibility of MyPrescribe. JMIR Hum Factors 2017; 4:e17. [PMID: 28765104 PMCID: PMC5558044 DOI: 10.2196/humanfactors.7153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/23/2017] [Accepted: 04/20/2017] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Chris Keyworth
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jo Hart
- Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Hong Thoong
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jane Ferguson
- Health Management Group, Alliance Manchester Business School, Faculty of Humanities, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Mary Tully
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Hansen CR, Walsh EK, Bradley CP, Sahm LJ. Teaching Prescribing: Just What the Doctor Ordered? A Thematic Analysis of the Views of Newly Qualified Doctors. PHARMACY 2017; 5:pharmacy5020032. [PMID: 28970444 PMCID: PMC5597157 DOI: 10.3390/pharmacy5020032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 05/22/2017] [Accepted: 06/09/2017] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Christina R Hansen
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork T12 YN60, Ireland.
| | - Elaine K Walsh
- Department of General Practice, University College Cork, Cork T12 XF62, Ireland.
| | - Colin P Bradley
- Department of General Practice, University College Cork, Cork T12 XF62, Ireland.
| | - Laura J Sahm
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork T12 YN60, Ireland.
- Pharmacy Department, Mercy University Hospital, Cork T12 WE28, Ireland.
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Ferguson J, Keyworth C, Tully MP. 'If no-one stops me, I'll make the mistake again': Changing prescribing behaviours through feedback; A Perceptual Control Theory perspective'. Res Social Adm Pharm 2017; 14:241-247. [PMID: 28283306 DOI: 10.1016/j.sapharm.2017.03.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Jane Ferguson
- Manchester Pharmacy, School, University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom.
| | - Chris Keyworth
- Manchester Pharmacy, School, University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom.
| | - Mary P Tully
- Manchester Pharmacy, School, University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom.
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Noble C, Brazil V, Teasdale T, Forbes M, Billett S. Developing junior doctors' prescribing practices through collaborative practice: Sustaining and transforming the practice of communities. J Interprof Care 2017; 31:263-272. [PMID: 28140691 DOI: 10.1080/13561820.2016.1254164] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Prescribing in acute healthcare settings is a complex interprofessional process with a high incidence of medication errors. Opportunities exist to improve prescribing learning through collaborative practice. This qualitative interview-based study aimed to investigate the development of junior doctors' prescribing capacity and how pharmacists contribute interprofessionally to this development and the prescribing practices of a medical community. The setting for this study was a large teaching hospital in Australia where ethical approval was gained before commencing the study. A constructionist approach was adopted and the interviews were held with a purposive sample of 34 participants including junior doctors (n = 11), clinical supervisors (medical; n = 10), and pharmacists (n = 13). Informed by workplace learning theory, interview data were thematically analysed. Three key themes related to pharmacists' contributions to prescribing practices emerged: building prescribing capacities of junior doctors through guidance and instruction; sustaining safe prescribing practices of the community in response to junior doctor rotations; and transforming prescribing practices of the community through workplace learning facilitation and team integration. These findings emphasize the important contributions made by pharmacists to building junior doctors' prescribing capacities that also assist in transforming the practices of that community. These findings suggest that rather than developing more conventional education programs for prescribing, further consideration should be given to interprofessional collaboration in everyday activities and interactions as a means to promote both effective learning for individuals and advancing the enactment of effective prescribing practice.
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Affiliation(s)
- Christy Noble
- a Medical Education Unit, Gold Coast Health , Gold Coast University Hospital , Southport , Queensland , Australia.,b School of Medicine , Griffith University , Southport , Queensland , Australia
| | - Victoria Brazil
- c Faculty of Health Sciences and Medicine , Bond University , Robina , Queensland , Australia.,d Diagnostic, Emergency and Medical Services, Gold Coast Health , Gold Coast University Hospital , Southport , Queensland , Australia
| | - Trudy Teasdale
- e Pharmacy, Gold Coast Health , Gold Coast University Hospital , Southport , Queensland , Australia
| | - Mark Forbes
- d Diagnostic, Emergency and Medical Services, Gold Coast Health , Gold Coast University Hospital , Southport , Queensland , Australia
| | - Stephen Billett
- f Professional, Continuing and Vocational Education , Griffith University , Mount Gravatt , Queensland , Australia
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R Hansen C, Bradley CP, Sahm LJ. Factors Influencing Successful Prescribing by Intern Doctors: A Qualitative Systematic Review. PHARMACY 2016; 4:pharmacy4030024. [PMID: 28970397 PMCID: PMC5419364 DOI: 10.3390/pharmacy4030024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/15/2016] [Accepted: 08/17/2016] [Indexed: 12/18/2022] Open
Abstract
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).
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Affiliation(s)
- Christina R Hansen
- School of Pharmacy, University College Cork, College Road, Cork T12 YN60, Ireland.
| | - Colin P Bradley
- Department of General Practice, University College Cork, Western Road, Cork T12 YN60, Ireland.
| | - Laura J Sahm
- School of Pharmacy, University College Cork, College Road, Cork T12 YN60, Ireland.
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork T12 WE28, Ireland.
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Pontefract SK, Hodson J, Marriott JF, Redwood S, Coleman JJ. Pharmacist-Physician Communications in a Highly Computerised Hospital: Sign-Off and Action of Electronic Review Messages. PLoS One 2016; 11:e0160075. [PMID: 27505157 PMCID: PMC4978401 DOI: 10.1371/journal.pone.0160075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 07/13/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Some hospital Computerized Physician Order Entry (CPOE) systems support interprofessional communication. The aim of this study was to investigate the effectiveness of pharmacist-physician messages sent via a CPOE system. METHOD Data from the year 2012 were captured from a large university teaching hospital CPOE database on: 1) review messages assigned by pharmacists; 2) details of the prescription on which the messages were assigned; and 3) details of any changes made to the prescription following a review message being assigned. Data were coded for temporal, message and prescription factors. Messages were analysed to investigate: 1) whether they were signed-off; and 2) the time taken. Messages that requested a measurable action were further analysed to investigate: 1) whether they were actioned as requested; and 2) the time taken. We conducted a multivariable analysis using Generalised Estimating Equations (GEE) to account for the effects of multiple factors simultaneously, and to adjust for any potential correlation between outcomes for repeated review messages on the same prescription. All analyses were performed using SPSS 22 (IBM SPSS Inc., Chicago, IL, USA), with p<0.05 considered significant. RESULTS Pharmacists assigned 36,245 review messages to prescriptions over the 12 months, 34,506 of which were coded for analysis after exclusions. Nearly half of messages (46.6%) were signed-off and 65.5% of these were signed-off in ≤ 48 hours. Of the 9,991 further analysed for action, 35.8% led to an action as requested by the pharmacist and just over half of these (57.0%) were actioned in ≤ 24 hours. Factors predictive of an action were the time since the prescription was generated (p<0.001), pharmacist grade (p<0.001), presence of a high-risk medicine (p<0.001), messages relating to reconciliation (p = 0.004), theme of communication (p<0.001), speciality, (p<0.001), category of medicine (p<0.001), and regularity of the prescription (p<0.001). CONCLUSION In this study we observed a lower rate of sign-off and action than we might have expected, suggesting uni-directional communication via the CPOE system may not be optimal. An established pharmacist-physician collaborative working relationship is likely to influence the prioritisation and response to messages, since a more desirable outcome was observed in settings and with grades of pharmacists where this was more likely. Designing systems that can facilitate collaborative communication may be more effective in practice.
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Affiliation(s)
- Sarah K. Pontefract
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - James Hodson
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - John F. Marriott
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Sabi Redwood
- School of Social and Community Medicine,University of Bristol, Bristol, United Kingdom
| | - Jamie J. Coleman
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
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Franchi C, Tettamanti M, Djade CD, Pasina L, Mannucci PM, Onder G, Gussoni G, Manfellotto D, Bonassi S, Salerno F, Nobili A. E-learning in order to improve drug prescription for hospitalized older patients: a cluster-randomized controlled study. Br J Clin Pharmacol 2016; 82:53-63. [PMID: 26922904 PMCID: PMC4917810 DOI: 10.1111/bcp.12922] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 01/12/2023] Open
Abstract
AIMS The aim of the study was to evaluate the effect of an e-learning educational program meant to foster the quality of drug prescription in hospitalized elderly patients. METHODS Twenty geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control (basic geriatric pharmacology notions). Logistic regression analysis was used in order to assess the effect of the intervention on the use of potentially inappropriate medication (PIM, primary outcome) at hospital discharge. Secondary outcomes were a reduced prevalence of at least one potential drug-drug interaction (DDI) and potentially severe DDI at discharge. Mortality rate and incidence of re-hospitalizations were other secondary outcomes assessed at the 12-month follow-up. RESULTS A total of 697 patients (347 in the intervention and 350 in the control arms) were enrolled. No difference in the prevalence of PIM at discharge was found between arms (OR 1.29 95%CI 0.87-1.91). We also found no decrease in the prevalence of DDI (OR 0.67 95%CI 0.34-1.28) and potentially severe DDI (OR 0.86 95%CI 0.63-1.15) at discharge, nor in mortality rates and incidence of re-hospitalization at 12-month follow-up. CONCLUSIONS This e-learning educational program had no clear effect on the quality of drug prescription and clinical outcomes in hospitalized elderly patients. Given the high prevalence of PIMs and potential DDIs recorded in the frame of this study, other approaches should be developed in order to improve the quality of drug prescription in this population.
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Affiliation(s)
- Carlotta Franchi
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
| | - Mauro Tettamanti
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
| | - Codjo Dgnefa Djade
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
| | - Luca Pasina
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
| | - Pier Mannuccio Mannucci
- A. Bianchi Bonomi Hemophilia and Thrombosis CenterIRCCS – Maggiore Hospital FoundationMilanItaly
| | - Graziano Onder
- Department of Geriatrics, Policlinico A. GemelliCatholic University of the Sacred HeartRomeItaly
| | | | - Dario Manfellotto
- Department of Internal MedicineOspedale Fatebenefratelli‐AFaRRomeItaly
| | - Stefano Bonassi
- Area of Clinical and Molecular EpidemiologyIRCCS – San Raffaele PisanaRomeItaly
| | - Francesco Salerno
- Department of Medical and Surgery SciencesIRCCS Policlinico San Donato, University of MilanItaly
| | - Alessandro Nobili
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
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