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Lvovschi VE, Carrouel F, Hermann K, Lapostolle F, Joly LM, Tavolacci MP. Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription. Front Public Health 2024; 12:1352833. [PMID: 38454991 PMCID: PMC10918692 DOI: 10.3389/fpubh.2024.1352833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Background Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon. Objective This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED. Methods A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression. Results A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not. Conclusion This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.
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Affiliation(s)
- Virginie E. Lvovschi
- Emergency Department, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Laboratory “Research on Healthcare Performance” (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Florence Carrouel
- Laboratory “Health, Systemic, Process” (P2S), UR4129, University Claude Bernard Lyon 1, University of Lyon, Lyon, France
| | - Karl Hermann
- Rouen University Hospital, CIC-CRB 1404, Rouen, France
| | - Frédéric Lapostolle
- SAMU 93, UF Research and Teaching quality, Avicenne Hospital-APHP, Bobigny, France
- INSERM U942, Sorbonne Paris Cité, Paris 13 University, Paris, France
| | - Luc-Marie Joly
- Emergency Department, Rouen University Hospital, Rouen, France
| | - Marie-Pierre Tavolacci
- Rouen University Hospital, CIC-CRB 1404, Rouen, France
- Univ Rouen Normandie, UMR1073 ADEN, Rouen, France
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Shetty Y, Kamat S, Tripathi R, Parmar U, Jhaj R, Banerjee A, Balakrishnan S, Trivedi N, Chauhan J, Chugh PK, Tripathi CD, Badyal DK, Solomon L, Kaushal S, Gupta K, Jayanthi M, Jeevitha G, Chatterjee S, Samanta K, Desai C, Shah S, Medhi B, Joshi R, Prakash A, Gupta P, Roy A, Chandy S, Ranjalkar J, Bright HR, Dikshit H, Mishra H, Roy SS, Kshirsagar N. Evaluation of prescriptions from tertiary care hospitals across India for deviations from treatment guidelines & their potential consequences. Indian J Med Res 2024; 159:130-141. [PMID: 38528817 PMCID: PMC11050754 DOI: 10.4103/ijmr.ijmr_2309_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND OBJECTIVES Irrational prescribing practices have major consequences on patient safety and also increase the economic burden. Real-life examples of impact of irrational prescription have potential to improve prescribing practices. In this context, the present study aimed to capture and evaluate the prevalence of deviations from treatment guidelines in the prescriptions, potential consequence/s of the deviations and corrective actions recommended by clinicians. METHODS It was a cross-sectional observational study conducted in the outpatient departments of tertiary care hospitals in India wherein the 13 Indian Council of Medical Research Rational Use of Medicines Centres are located. Prescriptions not compliant with the standard treatment guidelines and incomplete prescriptions with respect to formulation, dose, duration and frequency were labelled as 'prescriptions having deviations'. A deviation that could result in a drug interaction, lack of response, increased cost, preventable adverse drug reaction (ADR) and/or antimicrobial resistance was labelled as an 'unacceptable deviation'. RESULTS Against all the prescriptions assessed, about one tenth of them (475/4838; 9.8%) had unacceptable deviations. However, in 2667/4838 (55.1%) prescriptions, the clinicians had adhered to the treatment guidelines. Two thousand one hundred and seventy-one prescriptions had deviations, of which 475 (21.9%) had unacceptable deviations with pantoprazole (n=54), rabeprazole+domperidone (n=35) and oral enzyme preparations (n=24) as the most frequently prescribed drugs and upper respiratory tract infection (URTI) and hypertension as most common diseases with unacceptable deviations. The potential consequences of deviations were increase in cost (n=301), ADRs (n=254), drug interactions (n=81), lack of therapeutic response (n=77) and antimicrobial resistance (n=72). Major corrective actions proposed for consideration were issuance of an administrative order (n=196) and conducting online training programme (n=108). INTERPRETATION CONCLUSIONS The overall prevalence of deviations found was 45 per cent of which unacceptable deviations was estimated to be 9.8 per cent. To minimize the deviations, clinicians recommended online training on rational prescribing and administrative directives as potential interventions.
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Affiliation(s)
- Yashashri Shetty
- Department of Pharmacology & Therapeutics, Seth GSMC & KEM Hospital, Mumbai, Maharashtra, India
| | - Sandhya Kamat
- Department of Pharmacology & Therapeutics, Seth GSMC & KEM Hospital, Mumbai, Maharashtra, India
| | - Raakhi Tripathi
- Department of Pharmacology & Therapeutics, Seth GSMC & KEM Hospital, Mumbai, Maharashtra, India
| | - Urwashi Parmar
- Department of Pharmacology & Therapeutics, Seth GSMC & KEM Hospital, Mumbai, Maharashtra, India
| | - Ratinder Jhaj
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Aditya Banerjee
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | | | - Niyati Trivedi
- Department of Pharmacology, Medical College, Medical College, Baroda, Gujarat, India
| | - Janki Chauhan
- RUM Centre, Medical College, Medical College, Baroda, Gujarat, India
| | - Preeta Kaur Chugh
- Department of Pharmacology, VMMC & Safdarjung Hospital, New Delhi, India
| | - C. D. Tripathi
- Department of Pharamocology, The Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
| | - Dinesh Kumar Badyal
- Department of Pharmacology, Christian Medical College, Ludhiana, Punjab, India
| | - Lydia Solomon
- Department of Pharmacology, Christian Medical College, Ludhiana, Punjab, India
| | - Sandeep Kaushal
- Department of General Medicine, Christian Medical College, Ludhiana, Punjab, India
| | - Kanchan Gupta
- Department of General Medicine, Christian Medical College, Ludhiana, Punjab, India
| | - M. Jayanthi
- Department of Pharmacology, Post Graduate Institute of Medical Education & Research, Chandigarh, Punjab, India
| | - G. Jeevitha
- Department of Pharmacology, Post Graduate Institute of Medical Education & Research, Chandigarh, Punjab, India
| | - Suparna Chatterjee
- Department of Pharmacology, Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal, India
| | - Kalyan Samanta
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Chetna Desai
- Department of Pharmacology, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Samidh Shah
- Department of Pharmacology, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Bikash Medhi
- Department of Pharmacology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Rupa Joshi
- Department of Pharmacology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Ajay Prakash
- Department of Pharmacology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Pooja Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | - Atanu Roy
- RUM Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sujith Chandy
- Departments of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jaya Ranjalkar
- Departments of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Heber Rew Bright
- Departments of Pharmacy, Christian Medical College, Vellore, Tamil Nadu, India
| | - Harihar Dikshit
- Department of Pharmacology, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Hitesh Mishra
- Department of Pharmacology, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Sukalyan Saha Roy
- Department of Pharmacology, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
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Smith SE, Kerins J, McColgan-Smith S, Stewart F, Power A, Mardon J, Tallentire VR. The development of a marker system for Pharmacists' Behavioural Skills. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023; 31:520-527. [PMID: 37452687 DOI: 10.1093/ijpp/riad041] [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: 10/26/2022] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Pharmacists increasingly require complex behavioural skills to fulfil enhanced roles within healthcare teams. Behavioural marker systems are used to assess behavioural (or non-technical) skills during immersive simulation. This study aimed to develop a marker system for pharmacists' behavioural skills in patient-focussed care scenarios, and to investigate its content validity. METHODS Literature describing existing marker systems and the requisite behavioural skills of pharmacists were presented to two expert panels, alongside video examples of pharmacists in patient-focussed care simulations. The expert panels used this information to develop a new behavioural marker system. A third expert panel assessed the content validity, and the item- and scale-content validity indices were calculated. KEY FINDINGS The resulting tool contains four categories, each with three or four skill elements: situation awareness (gathering information; recognising and understanding information; anticipating, preparing and planning), decision-making and prioritisation (identifying options; prioritising; dealing with uncertainty; implementing or reviewing decisions), collaborative working (involving the patient; information sharing; leadership or followership), self-awareness (role awareness; speaking up; escalating care; coping with stress). The scale-content validity index was 0.95 (ideal) and the only item below the acceptable cut-off was 'leadership or followership' (0.7). CONCLUSIONS This tool is the first marker system designed to assess the behavioural skills of pharmacists in patient-focussed care scenarios. There is evidence of good content validity. It is hoped that once validated, the Pharmacists' Behavioural Skills marker system will enable pharmacy educators to provide individualised and meaningful feedback on simulation participants' behavioural skills.
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Affiliation(s)
- Samantha Eve Smith
- Scottish Centre for Simulation and Clinical Human Factors, Larbert, UK
- NHS Lothian, Edinburgh, UK
| | - Joanne Kerins
- Scottish Centre for Simulation and Clinical Human Factors, Larbert, UK
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | | | | | - Julie Mardon
- Scottish Centre for Simulation and Clinical Human Factors, Larbert, UK
| | - Victoria Ruth Tallentire
- Scottish Centre for Simulation and Clinical Human Factors, Larbert, UK
- NHS Lothian, Edinburgh, UK
- NHS Education for Scotland, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
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Shoaib H, Hussain YK, Ahmed S. Improving Clinician Confidence in Insulin Prescriptions at Discharge for Individuals With Newly Diagnosed Type 1 Diabetes. Cureus 2023; 15:e43643. [PMID: 37719599 PMCID: PMC10504911 DOI: 10.7759/cureus.43643] [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] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Background In a questionnaire, we found that pediatric clinicians at Basildon and Thurrock University Hospital (BTUH) have low confidence levels in prescribing multiple daily injections (MDI) for newly diagnosed pediatric patients with type 1 diabetes mellitus. We designed and evaluated locally tailored prescription guidance to improve confidence in MDI discharge prescriptions for pediatric doctors of all grades. Methods We designed a prescription guidance tool by adapting existing local guidelines to improve clinician familiarity with MDI prescriptions and prevent prescription errors. The intervention was delivered in a single pediatric unit to doctors of all levels. Feedback was collected, and the clinicians' confidence in their MDI prescriptions was evaluated before and after the intervention. Questionnaires were distributed to all pediatric doctors within the unit to assess their confidence in prescribing MDIs using a five-point Likert Scale. Furthermore, the questionnaires aimed to determine whether clinicians regularly consulted the existing local guidelines. Local guidelines were adapted in consultation with the local pediatric diabetic multidisciplinary team (MDT) and with reference to the East of England Pediatric Diabetes Network to present MDI guidance in a more concise format, which includes an example MDI discharge medication checklist. Following approval by the local guidelines management group, additional changes were made to enhance the practicality and accessibility of the discharge prescription guidance for clinicians. These guidelines were distributed to the pediatric MDT via email and displayed in visible areas of the department. Results Out of the 13 doctors surveyed, 10 provided pre- and post-intervention feedback (77%). Statistical significance was calculated using unpaired t-tests. Ninety percent of pediatric doctors routinely refer to local guidelines for guidance on MDI prescriptions. However, 50% of respondents felt that existing local guidelines were not easily accessible, given the time and effort required to locate them. The mean confidence score for completing MDI prescriptions at discharge before the intervention was 1.9 (SD: 0.83). After the intervention, it increased to 4 (SD: 0.63) (95% CI: 2.79-1.41, p<0.0001). Ninety percent of pediatric doctors felt that the design and display of the MDI guidelines optimized patient care. Conclusions Following the presentation of the project at a local audit and quality improvement (QI) meeting, the adapted guidelines were included in the junior doctor induction program at BTUH and made accessible on the local intranet. The production of locally tailored prescription guidance for MDI prescriptions at discharge has led to an increase in the confidence of pediatric doctors when writing their prescriptions. We aimed to continue updating this guidance as necessary and making further developments to enhance clinician confidence.
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Affiliation(s)
- Haris Shoaib
- Medicine, Basildon and Thurrock University Hospital, Basildon, GBR
| | - Yunus K Hussain
- Medicine, Basildon and Thurrock University Hospital, Basildon, GBR
| | - Shahida Ahmed
- Pediatrics, Basildon and Thurrock University Hospital, Basildon, GBR
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Grimes TC, Guinan EM. Interprofessional education focused on medication safety: a systematic review. J Interprof Care 2023; 37:131-149. [PMID: 35050843 DOI: 10.1080/13561820.2021.2015301] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Safe medication use necessitates interprofessional working, with calls to enhance interprofessional education (IPE) focusing on medication safety (MS) in healthcare professional (HCP) curricula. Little is known about the design, delivery or evaluation of such activities. This systematic literature review describes MS-focused IPE activities in pre-qualification HCP programmes. MedLine, EMBASE, CINAHL and ERIC were searched, relevant studies identified and data extracted. The McGill Mixed Methods Appraisal Tool was employed. The 3P (presage-process-product) theory structured deductive analysis. Thirty-one studies were included, reporting on 30 activities, mostly undertaken in North America or United Kingdom. Presage/Design: Most reported activities involved pharmacy, nursing, medical or physician assistant students learning with one or more other HCP group. Few studies matched student groups' skills or experiences. Few studies reported theoretical underpinnings. Process/Delivery: Multiple pedagogical approaches were employed, mostly social construction, and low- and high-fidelity simulation-based learning. Few studies reported learning outcomes or summative assessment, more reported formative assessment. Product/evaluation: Outcomes measured were learners' opinions, satisfaction or attitudes toward interprofessional working and findings were generally positive. Few studies reported on student development or outcomes specific to medication safety. Lack of integration of qualitative/quantitative components of mixed methods studies and limited outcome measurements' validity or reliability weakened study quality. MS-focused IPE for pre-qualification HCPs is well received by students. Design of future activities could be enhanced by employing theory and ensuring matching of students' and groups' skills, professional identity and learner attributes to enhance learning in an interprofessional setting. Future delivery should embed MS-focused IPE into the standard curricula to optimize constructive alignment, learner engagement, quality and drive development. The required skillset in pre-qualification HCP programmes to facilitate future safe medication practice, together with the associated learning outcomes and assessment approaches, should be defined. The quality of scholarly studies examining these activities needs improvement.
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Affiliation(s)
- T C Grimes
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, Dublin 2, Ireland
| | - E M Guinan
- School of Medicine, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland
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Ashour A, Phipps DL, Ashcroft DM. The role of non-technical skills in community pharmacy practice: an exploratory review of the literature. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 29:203-209. [PMID: 33793789 DOI: 10.1093/ijpp/riaa014] [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: 05/07/2020] [Accepted: 10/22/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Non-technical skills (NTS) are the cognitive and social skills that complement technical skills in safe and efficient practice, and include leadership, teamwork, task management, decision-making and situation awareness. Other areas within healthcare have heavily invested in producing taxonomies to aid training and assessment of NTS within their disciplines, and have found them to be essential for improving patient safety. In pharmacy, no validated taxonomy has been produced, nor has the existing literature been appraised to aid the future development of a validated taxonomy. OBJECTIVE(S) To examine the literature on NTS within a community pharmacy setting and establish the research conducted thus far on each NTS and how they are applied by community pharmacists. METHODS A literature search of six electronic databases (EMBASE, PsychINFO, Medline, SCOPUS, CINAHL Plus and HMIC) using the generic list of NTS identified in previous studies. Only empirical studies were included. Examples of behaviours or skills were extracted and categorised within each NTS. KEY FINDINGS Seventeen studies were identified that contained one or more examples of NTS specific to community pharmacy practice. Altogether, 16 elements were extracted. Four elements were identified within leadership and task management. A further three were identified within situation awareness and decision-making, and a final two within teamwork and communication. CONCLUSION A framework consisting of the skills and how they're applied has been presented which describe the NTS required by community pharmacists from the published literature. This framework can provide a foundation for further investigation into NTS use within pharmacy practice.
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Affiliation(s)
- Ahmed Ashour
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University The University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Denham L Phipps
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University The University of Manchester, Manchester, United Kingdom
| | - Darren M Ashcroft
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University The University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,NIHR School of Primary Care Research, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Brunton G, Oliver S, Thomas J. Innovations in framework synthesis as a systematic review method. Res Synth Methods 2020; 11:316-330. [PMID: 32090479 DOI: 10.1002/jrsm.1399] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 01/25/2020] [Accepted: 02/04/2020] [Indexed: 01/09/2023]
Abstract
Framework synthesis is one systematic review method employed to address health care practice and policy. Adapted from framework analysis methods, it has been used increasingly, using both qualitative and mixed-method systematic review methods. This article demonstrates a spectrum of approaches to framework synthesis that are dependent on the extent to which theory is tentative, emergent, refined, or established; and that stakeholder involvement may help to understand the topic's complexity where theory is more nascent. The choice of approach depends on the degree of match with existing theories and, in the absence of existing theory, the scale and heterogeneity of the literature to be managed.
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Affiliation(s)
- Ginny Brunton
- OntarioTech University, Faculty of Health Sciences, School of Nursing, Oshawa, ON, Canada
- University College London Institute of Education, EPPI-Centre, London, UK
- McMaster University, McMaster Midwifery Research Centre, Hamilton, ON, Canada
| | - Sandy Oliver
- University College London Institute of Education, EPPI-Centre, London, UK
- University of Johannesburg Faculty of Humanities, Africa Centre for Evidence, Johannesburg, South Africa
| | - James Thomas
- University College London Institute of Education, EPPI-Centre, London, UK
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Lloyd M. Comparison of pharmacy technicians’ and doctors’ medication transcribing errors at hospital discharge. Eur J Hosp Pharm 2020; 27:9-13. [DOI: 10.1136/ejhpharm-2018-001538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/15/2018] [Accepted: 06/19/2018] [Indexed: 11/03/2022] Open
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Kirsch V, Johannsen W, Thrien C, Herzig S, Matthes J. "Hopefully, I will never forget that again" - sensitizing medical students for drug safety by working on cases and simulating doctor-patient communication. GMS JOURNAL FOR MEDICAL EDUCATION 2019; 36:Doc17. [PMID: 30993175 PMCID: PMC6446464 DOI: 10.3205/zma001225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 08/23/2018] [Accepted: 11/23/2018] [Indexed: 06/09/2023]
Abstract
Objective: This project is part of the "PJ-STArT-Block", a one-week course preparing 10th semester medical students for their final practical year. The focus is on sensitizing students to aspects of medication safety by becoming aware of their skills and their deficits in terms of application and communication of pharmacological knowledge. The modules were evaluated regarding feasibility, acceptance and possible effects. Furthermore, the areas in which students see their pharmacological deficits or learning successes were gathered. Methods: In simulated physician-patient conversations, the students are to identify drug-related problems such as medication errors, adverse drug events or interactions. Together with their fellow students and under medical or pharmaceutical moderation, they then have to find solutions for the identified problems and communicate these solutions to the patients. Based on paper cases, students practice, reflect, and discuss the research of reliable information about drugs and medication therapy. The written evaluation included the evaluation by school grades and the possibility of comments in free text. A content analysis of interviews with students at the beginning of the project aimed to identify areas of pharmacology in which they see their own deficits. Results: Evaluation results including the free text comments indicate students' acceptance of our pharmacology modules. According to this, the students realize the importance of aspects relevant for medication safety. The areas mentioned in 35 interviews in which students localize deficits, correspond to the topics that were intended when conceiving the modules and which are important for medication safety (e.g. interactions, adverse drug effects, dosages). Conclusion: Implementation of context-based, application-oriented teaching formats as recently claimed for pharmacological education to improve the quality of prescriptions, is possible, as the Cologne example shows. The student evaluation turns out positively and indicates a critical self-reflection. The students identified various pharmacological deficits in themselves, which have since been confirmed and quantified in another study.
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Affiliation(s)
- Verena Kirsch
- Universität zu Köln, Zentrum für Pharmakologie, Köln, Germany
| | | | - Christian Thrien
- Universität zu Köln, Medizinische Fakultät, Studiendekanat, Kölner Interprofessionelles Skills Lab und Simulationszentrum (KISS), Köln, Germany
| | - Stefan Herzig
- Universität zu Köln, Zentrum für Pharmakologie, Köln, Germany
- Technische Hochschule Köln, Köln, Germany
| | - Jan Matthes
- Universität zu Köln, Zentrum für Pharmakologie, Köln, Germany
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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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11
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Exploring the impact of pharmacist-led feedback on prescribing behaviour: A qualitative study. Res Social Adm Pharm 2018; 14:545-554. [DOI: 10.1016/j.sapharm.2017.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/07/2017] [Accepted: 06/17/2017] [Indexed: 11/21/2022]
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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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Yeung EYH, Alexander M. Use of junior doctor‐led peer education to improve antibiotic stewardship. Br J Clin Pharmacol 2017; 83:2831-2832. [DOI: 10.1111/bcp.13375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 06/29/2017] [Accepted: 07/09/2017] [Indexed: 11/29/2022] Open
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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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Hauser K, Koerfer A, Niehaus M, Albus C, Herzig S, Matthes J. The prescription talk - an approach to teach patient-physician conversation about drug prescription to medical students. GMS JOURNAL FOR MEDICAL EDUCATION 2017; 34:Doc18. [PMID: 28584866 PMCID: PMC5450434 DOI: 10.3205/zma001095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 01/31/2017] [Accepted: 02/15/2017] [Indexed: 06/07/2023]
Abstract
Background: Medication communication from physicians to patients often is poor, by this among others enhancing the risk of non-adherence. In this context, a neglect regarding the prescription talk has been complained. Aim of the project: In a newly developed elective medical students work on physician-patient conversations dealing with drug prescription. Essential aspects related to an effective and safe drug treatment are combined with steps of shared decision-making. Together with a tutor, students develop a (model) conversation guide that might be tailored according to individual needs and views. Description/Methods: In a one-week course 3rd-5th year medical students treat a paper case according to problem-based learning. This is accompanied by a one-hour lecture and literature provided on an online learning platform (ILIAS). During a workshop, aspects of drug treatment and patient participation are integrated into a guide for a prescription talk. At the end of the week the students are invited to apply the (if need be individualized) guide in a simulated physician-patient communication with an actor. The conversation is evaluated using a checklist based upon the (model) conversation guide. Results: Informal and formalized feedback indicate high acceptance and satisfaction of participants with this elective. The checklist turned out to be of acceptable to good reliability with mostly selective items. Portfolio entries and written evaluation suggest that participants' positions and attitudes are influenced.
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Affiliation(s)
- Katarina Hauser
- Universität zu Köln, Zentrum für Pharmakologie, Institut II, Köln, Deutschland
| | - Armin Koerfer
- Uniklinik Köln, Klinik und Poliklinik für Psychosomatik und Psychotherapie, Köln, Deutschland
| | - Mathilde Niehaus
- Universität zu Köln, Humanwissenschaftliche Fakultät, Lehrstuhl für Arbeit und Berufliche Rehabilitation, Köln, Deutschland
| | - Christian Albus
- Uniklinik Köln, Klinik und Poliklinik für Psychosomatik und Psychotherapie, Köln, Deutschland
| | - Stefan Herzig
- Universität zu Köln, Zentrum für Pharmakologie, Institut II, Köln, Deutschland
- Universität zu Köln, Rektorat, Köln, Deutschland
| | - Jan Matthes
- Universität zu Köln, Zentrum für Pharmakologie, Institut II, Köln, Deutschland
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Hauser K, Matthes J. Medical students' medication communication skills regarding drug prescription-a qualitative analysis of simulated physician-patient consultations. Eur J Clin Pharmacol 2017; 73:429-435. [PMID: 28091704 DOI: 10.1007/s00228-016-2192-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/28/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Poor medication communication of physicians to patients is detrimental, e.g. for medication adherence. Reasons for physicians' deficits in medication communication may be unfavourable conditions in daily practice or already insufficient training during their (undergraduate) medical studies. We explored medical students' communication on new medications in simulated physician-patient conversations to identify actual deficits indicating apparent educational needs. METHODS Fifth year medical students attending a mandatory course at the University of Cologne had simulated physician-patient consultations aiming at drug prescription. In 2015, 21 consultations were recorded, transcribed and subjected to qualitative content analysis based on the method of inductive coding. RESULTS Even essential information on drug therapy was often lacking (e.g. adverse effects, drug administration). Some aspects were addressed more frequently than others. This seemed to differ depending on the diagnosis underlying the particular treatment (acute event vs. chronic disease). The extent of information on drug treatments given in simulated physician-patient consultations varied significantly between students. CONCLUSIONS Fifth year medical students showed appreciable deficits in communicating drug prescriptions to patients though there were remarkable inter-individual differences. Our findings suggest that communication on drug therapy to patients is no self-evolving skill. Thus, there is obviously a need for emphasizing medication communication in the training of medical students. Communication aids specifically aiming at medication communication might facilitate learning of adequate medication communication skills.
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Affiliation(s)
- Katarina Hauser
- Department of Pharmacology II, University of Cologne, Gleueler Strasse 24, 50931, Köln (Cologne), Germany
| | - Jan Matthes
- Department of Pharmacology II, University of Cologne, Gleueler Strasse 24, 50931, Köln (Cologne), Germany.
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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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Dearden E, Mellanby E, Cameron H, Harden J. Which non-technical skills do junior doctors require to prescribe safely? A systematic review. Br J Clin Pharmacol 2015; 80:1303-14. [PMID: 26289988 DOI: 10.1111/bcp.12735] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 07/24/2015] [Accepted: 08/03/2015] [Indexed: 11/27/2022] Open
Abstract
AIMS Prescribing errors are a major source of avoidable morbidity and mortality. Junior doctors write most in-hospital prescriptions and are the least experienced members of the healthcare team. This puts them at high risk of error and makes them attractive targets for interventions to improve prescription safety. Error analysis has shown a background of complex environments with multiple contributory conditions. Similar conditions in other high risk industries, such as aviation, have led to an increased understanding of so-called human factors and the use of non-technical skills (NTS) training to try to reduce error. To date no research has examined the NTS required for safe prescribing. The aim of this review was to develop a prototype NTS taxonomy for safe prescribing, by junior doctors, in hospital settings. METHODS A systematic search identified 14 studies analyzing prescribing behaviours and errors by junior doctors. Framework analysis was used to extract data from the studies and identify behaviours related to categories of NTS that might be relevant to safe and effective prescribing performance by junior doctors. Categories were derived from existing literature and inductively from the data. RESULTS A prototype taxonomy of relevant categories (situational awareness, decision making, communication and team working, and task management) and elements was constructed. CONCLUSIONS This prototype will form the basis of future work to create a tool that can be used for training and assessment of medical students and junior doctors to reduce prescribing error in the future.
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Affiliation(s)
- Effie Dearden
- Centre for Medical Education, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh
| | - Edward Mellanby
- Centre for Medical Education, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh
| | - Helen Cameron
- Centre for Medical Education, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh
| | - Jeni Harden
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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