European List of Essential Medicines for Medical Education: a protocol for a modified Delphi study

INTRODUCTION

Junior doctors are responsible for a substantial number of prescribing errors, and final-year medical students lack sufficient prescribing knowledge and skills just before they graduate. Various national and international projects have been initiated to reform the teaching of clinical pharmacology and therapeutics (CP&T) during undergraduate medical training. However, there is as yet no list of commonly prescribed and available medicines that European doctors should be able to independently prescribe safely and effectively without direct supervision. Such a list could form the basis for a European Prescribing Exam and would harmonise European CP&T education. Therefore, the aim of this study is to reach consensus on a list of widely prescribed medicines, available in most European countries, that European junior doctors should be able to independently prescribe safely and effectively without direct supervision: the European List of Essential Medicines for Medical Education.

METHODS AND ANALYSIS

This modified Delphi study will recruit European CP&T teachers (expert group). Two Delphi rounds will be carried out to enable a list to be drawn up of medicines that are available in ≥80% of European countries, which are considered standard prescribing practice, and which junior doctors should be able to prescribe safely and effectively without supervision.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Review Committee of VU University Medical Center (no. 2020.335) and by the Ethical Review Board of the Netherlands Association for Medical Education (approved project no. NVMO-ERB 2020.4.8). The European List of Essential Medicines for Medical Education will be presented at national and international conferences and will be submitted to international peer-reviewed journals. It will also be used to develop and implement the European Prescribing Exam.

A mixed-methods evaluation of the impact of a pharmacist-led feedback pilot intervention on insulin prescribing in a hospital setting

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.

Identification of medication errors through a monitoring and minimization program in outpatients in Colombia, 2018-2019

Introducción

El uso de medicamentos puede conllevar errores de medicación que desemboquen en la hospitalización del paciente, el aumento de los costos relacionados con la atención e, incluso, la muerte.

Objetivos

Determinar la prevalencia de errores de medicación notificados en un sistema de información de farmacovigilancia en Colombia entre el 2018 y el 2019.

Materiales y métodos

Se hizo un estudio observacional a partir del registro de errores de medicación de un sistema de farmacovigilancia que cubre a 8,5 millones de pacientes ambulatorios afiliados al sistema de salud de Colombia. Los errores se categorizaron en ocho grupos de la A (situaciones potenciales de error) hasta la I (error que pudo llevar a la muerte). Se hizo el análisis descriptivo y se estableció la prevalencia de los errores de medicación.

Resultados

Durante los años 2018 y 2019, se reportaron 29.538 errores de medicación en pacientes ambulatorios, con una prevalencia general de 1,93 por cada 10.000 medicamentos dispensados. En el 0,02% (n=6) de los casos, se presentaron errores que llegaron a afectar a los pacientes y causaron daño (tipos E, F e I). La mayoría de los errores se asoció con la dispensación (n=20.636; 69,9%) y la posible causa más común fue la falta de concentración en el momento de dispensar los medicamentos (n=9.185; 31,1%). Los grupos farmacológicos más implicados en errores de medicación fueron los antidiabéticos (8,0%), los inhibidores del sistema renina-angiotensina (7,6%) y los analgésicos (6,0%).

Conclusiones

Los errores de medicación son relativamente poco frecuentes y con mayor frecuencia se catalogan como circunstancias o eventos capaces de generar un error de tipo A. Muy pocas veces, pueden causarle daño al paciente, incluso, hasta la muerte.

Applying medicines reconciliation indicators in two UK hospitals: a feasibility study

Objectives

The aim of this study was to apply the Medicines reconciliation (MR) indicators and to assess their feasibility for use with patients on admission.

Methods

This is a mixed-methods study conducted in two large teaching hospitals in the north-west of England. There were two phases: (1) a prospective direct non-participant observational study was conducted on a small sample of five pharmacists in each hospital, who were observed while they conducted the MR process without interference by the investigator and (2) pharmacy staff conducting MR were asked to complete the MR data collection form, comprising various clinical information during the working hours of a selected weekday for all MRs conducted for patients admitted to hospital during that day. SPSS V20 was used for data analysis.

Key findings

In the first phase, five MR indicators were found not to be feasible and three not adequately assessed, while 33 indicators were considered feasible to be used in a hospital setting. In the second phase, 33 indicators were considered feasible to assess MR on admission to the hospital, 14 indicators were found feasible to assess main aspects of the MR process, and 18 indicators were found feasible to assess detailed aspects of the MR process. The majority of admissions were unplanned. Roughly half 45.4% of the patients admitted to hospital A were reconciled, while in hospital B 52% were reconciled.

Conclusion

The use of different methods to collect data was effective in providing valuable information as well as overcoming the potential limitation of each method.

Development of the adult complexity tool for pharmaceutical care (ACTPC) in hospital: A modified Delphi study

BACKGROUND

Hospital pharmacists play an essential role in patient care; however, a lack of resources means pharmacists are unable to review all patients daily. Consequently, there is a demand for reliable screening tools to allocate care to patients with urgent and/or complex pharmaceutical needs. Several tools have been developed, but no broad consensus exists on the design of a screening tool to be used in the adult hospital setting.

OBJECTIVE

To obtain expert consensus on the design of a pharmaceutical care complexity screening tool for use on admission to hospital.

METHODS

Two Delphi studies were conducted: the first sought to gain consensus from experts including pharmacists, academics and physicians on the components of a pharmaceutical complexity tool, the second to achieve consensus from UK chief pharmacists and clinical service pharmacy managers on the clinical appropriateness and practicality of the tool. Tool components and Delphi statements were identified and refined from our previous systematic review, UK survey and interview study of prioritisation tools. A valid definition for consensus was used.

RESULTS

Over 300 components were extracted from the interview data and systematic review and then refined for inclusion in the first Delphi study. Thirty-three experts completed Delphi One and consensus was reached on 92 components. Components were grouped into demographic, clinical and medication components and condensed to 33 items, which were included in the first draft of the Adult Complexity Tool for Pharmaceutical Care (ACTPC). The tool stratified patients into highly, moderately or least complex. Forty expert panellists completed Delphi Two and consensus was reached on review frequency and experience of pharmacy practitioner at each level. These decisions were incorporated into the final version of the ACTPC.

CONCLUSIONS

The ACTPC is the first systematically designed and internationally agreed tool for use on medical admission to hospital. It has potential to enable the delivery of targeted patient-centred pharmaceutical care.

Automation of in-hospital pharmacy dispensing: a systematic review

OBJECTIVES

The current systematic review (SR) was undertaken to identify and summarise the published literature reporting on the clinical and economic value of automated in-hospital pharmacy services with a primary focus on systems supporting the dispensing of medicines.

METHODS

Literature searches were conducted in MEDLINE, Embase and the Cochrane Library on 17 December 2017 to identify English-language publications investigating any automated dispensing systems (ADSs) in the inpatient setting to include central pharmacy and ward-based systems.

RESULTS

4320 publications were screened by title and abstract and 45 of 175 full publications screened were included. Grey literature searching identified an additional three publications. Therefore, 48 publications relating to ADSs were eligible for inclusion. Although a relatively large evidence base was identified as part of the current SR, the eligible studies were inconsistent in terms of their design and the format of reporting of outcomes. The studies demonstrate that both pharmacy and ward-based ADSs offer benefits over traditional manual dispensing methods in terms of clinical and economic outcomes. The primary benefits following implementation of an ADS include reductions in medication errors, medication administration time and costs. Studies examining optimisation/inventory management strategies/refill programmes for these systems suggest that optimal implementation of the ADS is required to ensure that clinical success and economic benefits are maximised.

CONCLUSIONS

The published evidence suggests positive impacts of ADS and should encourage hospitals to invest in automation, with a global strategy to improve the reliability and the efficiency of the medication process. However, one of the key findings of the current SR is the need for further data from adequately powered studies reporting clinically relevant outcomes which would allow for robust, evidence-based recommendations on the return on investment of the technologies. These studies would probably contribute to a larger adoption of these technologies by European hospitals.

Hospital medication errors: a cross-sectional study

BACKGROUND

Medication errors (MEs) are among the most common types of incidents reported in Australian and international hospitals. There is no uniform method of reporting and reducing these errors. This study aims to identify the incidence, time trends, types and factors associated with MEs in a large regional hospital in Australia.

METHODS

A 5-year cross-sectional study.

RESULTS

The incidence of MEs was 1.05 per 100 admitted patients. The highest frequency of errors was observed during the colder months of May-August. When distributed by day of the week, Mondays and Tuesdays had the highest frequency of errors. When distributed by hour of the day, time intervals from 7 am to 8 am and from 7 pm to 8 pm showed a sharp increase in the frequency of errors. One thousand and eighty-eight (57.8%) MEs belonged to incidence severity rating (ISR) level 4 and 787 (41.8%) belonged to ISR level 3. There were six incidents of ISR level 2 and only one incident of ISR level 1 reported during the five-year period 2014-2018. Administration-only errors were the most common accounting for 1070 (56.8%) followed by prescribing-only errors (433, 23%). High-risk medications were associated with half the number of errors, the most common of which were narcotics (17.9%) and antimicrobials (13.2%).

CONCLUSIONS

MEs continue to be a problem faced by international hospitals. Inexperience of health professionals and nurse-patient ratios might be the fundamental challenges to overcome. Specific training of junior staff in prescribing and administering medication and nurse workload management could be possible solutions to reducing MEs in hospitals.

Inter-rater reliability of assessments regarding the quality of drug treatment, and drug-related hospital admissions

AIMS

To investigate inter-rater agreement on the quality of drug treatment, and the relationship between the drug treatment and hospital admission.

METHODS

Three specialist physicians and two resident physicians determined, independently and in consensus, the quality of drug treatment from an overall medical perspective, and its association with admission, in 30 randomly selected patients (50% female, median age 72 years) admitted to Sahlgrenska University Hospital, Sweden, in April 2018. The inter-rater agreement was evaluated with Gwet's agreement coefficient (AC₁ ).

RESULTS

In all, 200 (95%) out of 210 drugs at admission and 238 (97%) out of 245 drugs at discharge were assessed as reasonable drug treatment by all assessors. Conversely, none of the drugs at admission, and two at discharge, were assessed as unreasonable drug treatment by all assessors (AC₁ : 0.88 and 0.94 [all], 0.86 and 0.95 [specialists], 0.92 and 0.92 [residents], respectively). The assessments regarding the association between the drug treatment and the hospital admission (not related or main/contributory reason) were consistent between the assessors for 16 out of 30 patients (AC₁ : 0.67 [all], 0.74 [specialists], 0.54 [residents]). In none of the three cases where the hospital admission was considered possibly attributable to a prescribing error did the assessors make consistent assessments.

CONCLUSIONS

As the inter-rater agreement ranged between weak and almost perfect, the reliability of assessments of drug treatment quality, as well as adverse consequences, appears to be a methodological concern. To yield acceptably reliable results regarding both drug treatment aspects at issue, specialist physicians should be involved.

Prescriber behaviours that could be targeted for change: An analysis of behaviours demonstrated during prescription writing in children

BACKGROUND

The prescribing process for children with cancer is complex, and errors can occur at any step. As a result, many interventions have been used to reduce errors. However, few of them have been designed based on an understanding of the prescriber behaviour that can lead to errors. In order to design effective behaviour change interventions, it is important first to understand the prescribing process and identify prescriber behaviours that could be targeted for change.

OBJECTIVES

To describe the prescribing process in a paediatric oncology ward and to identify prescriber behaviours during prescription writing that could be targeted to reduce errors.

METHODS

This study employed two sequential phases. First, the prescribing process was observed and then described using the hierarchical task analysis (HTA) method. Second, prescriber tasks identified from the HTA were analysed using the behaviour change wheel (BCW) approach to identify promising behaviours for change. These identified behaviours were prioritised based on information collected from four focus groups with prescribers and chart review of errors made in the ward.

RESULTS

The prescribing process was complex and involved multiple tasks performed in varying orders. Applying the BCW identified thirty-two candidate behaviours for potentially reducing prescribing errors. However, after prioritization, only two emerged as promising candidate behaviours for intervention: writing drug indications at the time of prescribing and using a pre-written order when ordering medications through electronic prescribing.

CONCLUSIONS

This research suggests that two behaviours could be promising in reducing errors. Having identified these behaviours, future work could explore what needs to change with respect to individuals and their work environments to achieve the desired change in these identified behaviours.

Harm Prevalence Due to Medication Errors Involving High-Alert Medications: A Systematic Review

OBJECTIVE

The aim of the study was to determine the prevalence and main types of harm caused by high-alert medication after medication errors (MEs) in hospitals.

METHOD

A literature systematic review was conducted on PubMed, Scopus, Web of Science, and Lilacs. Eligible studies published until June 2017 were included.

RESULT

Of 6244 studies identified through searching four electronic databases, five studies meeting the selection criteria of this study were analyzed. There was wide variation in the overall prevalence of harm due to MEs involving HAM, from 3.8% to 100%, whereas the pooled prevalence was 16.3%. Overall, 0.01% of harm caused by MEs involving HAM resulted in death. The severity of errors ranged from 0.1% to 19.2% for moderate errors, 0.2% to 15.4% for serious errors, and 1.9% lethal to the patients. The highest prevalences of harm occurred after errors involving potassium chloride 15%, insulin, and epoprostenol. The lowest prevalence of harm was related to errors of anticoagulants administration. The methodological heterogeneity limited direct comparisons among the studies.

CONCLUSIONS

Of the 15 drugs on the list of Institute for Safe Medication Practices HAMs in the United States and Brazil, nine did not present scientific evidence of the potential for harm. In general, few studies, characterized by methodological and conceptual heterogeneity, were performed to determine the harm prevalence resulting from errors involving these drugs.

Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting

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.

A cross-sectional study of errors in physicians orders' of antiseizure medications among people with epilepsy from rural India

AIMS

To enumerate and classify errors in physicians' orders of antiseizure medications (ASMs) to people with epilepsy presenting to neurology clinic.

METHODS

This cross-sectional study was conducted in the neurology clinic of a teaching hospital catering to a predominantly rural population. People in whom a diagnosis of epilepsy was confirmed and who presented for the first time with a prior prescription for antiseizure medication/s were included. Their immediate previous prescriptions were assessed for errors, enumerated and classified according to WHO guidelines for prescription writing.

RESULTS

Hundred prescriptions of 334 patients screened were analyzed. The number of ASMs prescribed to a participant was 2 ± 0.6 (mean ± SD). We identified a mean of 5 ± 4 (median: 3; range: 1-7) errors in each order. These included superscription errors, e.g., missing information on seizure control and frequency (n = 90, 90%), generic name (n = 62, 62%), patient identifiers (n = 57, 57%), prescribers' identifiers (n = 29, 29%) and diagnosis or indication for prescribing the medication/s (n = 55, 55%). The most common inscription and subscription errors were dosing errors (22%) and pharmaceutical form errors (20%) followed by omission (13%), duplication (13%), substitution (12%), commission (9%) and frequency errors (8%). Errors were more common among prescriptions provided by primary-care and Ayurvedic, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) physicians compared to specialists (P < 0.05).

CONCLUSIONS

Errors are common among medication orders provided by non-specialist and specialist physicians. Primary care and AYUSH are more liable to make errors underscoring the need to educate them in basic epilepsy treatment.

Model-Informed Precision Dosing: Background, Requirements, Validation, Implementation, and Forward Trajectory of Individualizing Drug Therapy

Model-informed precision dosing (MIPD) has become synonymous with modern approaches for individualizing drug therapy, in which the characteristics of each patient are considered as opposed to applying a one-size-fits-all alternative. This review provides a brief account of the current knowledge, practices, and opinions on MIPD while defining an achievable vision for MIPD in clinical care based on available evidence. We begin with a historical perspective on variability in dose requirements and then discuss technical aspects of MIPD, including the need for clinical decision support tools, practical validation, and implementation of MIPD in health care. We also discuss novel ways to characterize patient variability beyond the common perceptions of genetic control. Finally, we address current debates on MIPD from the perspectives of the new drug development, health economics, and drug regulations.

Evaluation of the completeness of information sources used to prepare the best possible medication histories at a tertiary teaching hospital in Jordan

OBJECTIVES

In this study we aimed to evaluate the completeness of three different medication information sources that are commonly used to collect and obtain the Best Possible Medication History (BPMH).

METHODS

This is an observational study which was held at Jordan University Hospital. After identifying eligible patients, the BPMH was obtained from three different sources separately. These sources include medical file, pharmacy database, and patients' interview. Information from all of these sources was compiled to create the BPMH. The BPMH was used as the standard against which every other information source was compared and given a "completeness score" according to a systematic scoring system.

RESULTS

Among the 196 participating patients who were included in the study, 113 (57.7%) were recruited from internal medicine and 83 (42.3%) from surgical department. Patients' interview showed the highest median completeness score (71.4%) among the three used sources followed by pharmacy database (35.3%), and medical files (28.2%). The median completeness score for the compiled BPMH obtained by the pharmacist was 93.0%. The compiled BPMH completeness score was inversely proportional to the numbers of medications in the compiled BPMH (R = -.392, P value < .001). Moreover, patients with lower income showed better median BPMH completeness score compared with those with higher income (95.2% (IQR = 16.7%) vs 88.9% (IQR = 15.7%), respectively, P value = .042).

CONCLUSION

The results show that pharmacist's interview with the patients scored the highest percentage of completeness compared with hospital pharmacy database and medical file and is, therefore, considered more comprehensive in obtaining the BPMH.

Twelve tips for facilitating medical students prescribing learning on clinical placement

Prescribing is a complex clinical skill requiring mastery by the end of basic medical training. Prescribing errors are common in newly qualified doctors, aligned with expressed anxiety about prescribing, particularly with high-risk medications. Learning about prescribing needs to start early in medical training, underpinned by regular opportunities for reflective practice. Authentic learning within the clinical work environment is more effective than lecture based learning and allows potential immediate feedback. Educational strategies should support prescribing learning underpinned by appropriate formative and summative assessments. Students should routinely be expected to use resources including an online formulary, sustained through tracking individual progress through use of their own personal formulary or 'p' drugs. Regular prescribing practice with embedded feedback during undergraduate training will help to ensure newly qualified doctors are more confident and competent prescribers.

Repurposing Clinical Decision Support System Data to Measure Dosing Errors and Clinician-Level Quality of Care

We aimed to develop and validate an instrument to detect hospital medication prescribing errors using repurposed clinical decision support system data. Despite significant efforts to eliminate medication prescribing errors, these events remain common in hospitals. Data from clinical decision support systems have not been used to identify prescribing errors as an instrument for physician-level performance. We evaluated medication order alerts generated by a knowledge-based electronic prescribing system occurring in one large academic medical center's acute care facilities for patient encounters between 2009 and 2012. We developed and validated an instrument to detect medication prescribing errors through a clinical expert panel consensus process to assess physician quality of care. Six medication prescribing alert categories were evaluated for inclusion, one of which - dose - was included in the algorithm to detect prescribing errors. The instrument was 93% sensitive (recall), 51% specific, 40% precise, 62% accurate, with an F1 score of 55%, positive predictive value of 96%, and a negative predictive value of 32%. Using repurposed electronic prescribing system data, dose alert overrides can be used to systematically detect medication prescribing errors occurring in an inpatient setting with high sensitivity.

Views and experiences of decision-makers on organisational safety culture and medication errors

BACKGROUND

In 2017, the World Health Organization published "Medication Without Harm, WHO Global Patient Safety Challenge," to reduce patient harm caused by unsafe medication use practices. While the five objectives emphasise the need to create a framework for action, engaging key stakeholders and others, most published research has focused on the perspectives of health professionals. The aim was to explore the views and experiences of decision-makers in Qatar on organisational safety culture, medication errors and error reporting.

METHOD

Qualitative, semi-structured interviews were conducted with healthcare decision-makers (policy-makers, professional leaders and managers, lead educators and trainers) in Qatar. Participants were recruited via purposive and snowball sampling, continued to the point of data saturation. The interview schedule focused on: error causation and error prevention; engendering a safety culture; and initiatives to encourage error reporting. Interviews were digitally recorded, transcribed and independently analysed by two researchers using the Framework Approach.

RESULTS

From the 21 interviews conducted, key themes were the need to: promote trust within the organisation through articulating a fair blame culture; eliminate management, professional and cultural hierarchies; focus on team building, open communication and feedback; promote professional development; and scale-up successful initiatives. There was recognition that the current medication error reporting processes and systems were suboptimal, with suggested enhancements in themes of promoting a fair blame culture and open communication.

CONCLUSION

These positive and negative aspects of organisational culture can inform the development of theory-based interventions to promote patient safety. Central to these will be the further development and sustainment of a "fair" blame culture in Qatar and beyond.

What Safety Events Are Reported For Ambulatory Care? Analysis of Incident Reports from a Patient Safety Organization

INTRODUCTION

Health care staff document patient safety events using incident reporting systems, which are compiled within Patient Safety Organization databases. Researchers sought to describe the patterns and characteristics of incident reporting behaviors for ambulatory care from in-situ reporting systems from the United States.

METHODS

The team analyzed safety reports in ambulatory settings collected from a Patient Safety Organization comprising 400 hospital members in 10 states, from May 2012 to October 2018. All events involving moderate harm, severe harm, and death were included, as well as subsamples of events with missing harm, no harm, and mild harm. The team deductively coded incident types and if patient or caregiver challenges were involved. A multivariate logistic regression was conducted to identify predictors of higher harm (severe harm and death) among safety events reported.

RESULTS

Of 2,701 events, there were 51 deaths, 159 severe harm events, 1,180 moderate harm, 926 mild harm, 384 no harm, and 1 unknown. Most were from outpatient subspecialty care, while 5.2% were from home/community, and 2.1% were from primary care. Medication-related events were most common (45.3%). In multivariate analysis, diagnostic errors (adjusted odds ratio [aOR] 11.5), patient/caregiver challenges (aOR 2.2), and events in the home/community (aOR 2.0) and in psychiatric settings (aOR 5.0) were associated with higher harm.

CONCLUSION

Outpatient reporting systems are limited for primary care and home/community settings, but ambulatory care systems report more harmful events related to diagnosis and patient and caregiver challenges. Improved standardization of reporting, focus on diagnosis, and novel approaches of safety reporting that engage patients will be necessary to improve capture of preventable events affecting patients and to develop system-level solutions.

Investigating the incidence, nature, severity and potential causality of medication errors in hospital settings in Qatar

Background Medication errors are a major public health concern that negatively impact patient safety and health outcomes. Effective and efficient medication error reporting systems and practices are imperative in reducing error incidence and severity. Objective The objectives were to quantify the incidence, nature and severity of medication errors, and to explore potential causality using a theoretical framework. Setting The study was conducted at Hamad Medical Corporation, the largest public funded academic healthcare center in the state of Qatar. Methods A retrospective review of medication error reports submitted to the Hamad Medical Corporation incident reporting system during 2015 to 2017. Data related to number of reports, reporter, medication, severity and outcomes were extracted. Reason’s Accident Causation Model was used as a theoretical framework for identifying potential causality. Two researchers independently categorized errors as: active failures (e.g. forgetting to administer medication at scheduled time); error provoking conditions (e.g. medication prescribed by an unauthorized physician and administered to the patient); and latent failures (e.g. organizational factors, lack of resources). Main outcome measures Incidence, classes of medications, reporter, error severity and outcomes, potential causality. Results A total of 5103 reports provided sufficient information to be included in the study giving an estimated error incidence of 0.044% of prescribed medication items. Most of the reports (91.5%, n = 4667) were submitted by pharmacists and majority (87.9%, n = 4485) were prescribing errors. The most commonly reported medications were anti-infectives for systemic use (22.0%, n = 1123) followed by medications to treat nervous system disorders (17.2%, n = 876). Only three errors reported to have caused temporary harm requiring intervention while one contributed to or resulted in temporary harm requiring initial or prolonged hospitalization. In terms of potential causality of medication errors, the majority (91.5%, n = 4671) were classified as active failures. Conclusion Almost all reports were submitted by pharmacists, indicating likely under-reporting affecting the actual incidence. Effort is required to increase the effectiveness and efficiency of the reporting system. The use of the theoretical framework allowed identification of potential causality, largely in relation to active failures, which can inform the basis of interventions to improve medication safety.

Investigating prescribing errors in the emergency department of a large governmental hospital in Jordan

Background

Although prescribing errors (PEs) are the most common type of medication errors and cause morbidity and mortality, they have been rarely studied.

Objective

The study aimed to investigate PEs incidence, types, severity, causes, predictors, pharmacists' interventions accepted by doctors and computer-related errors.

Setting

This study was conducted in the emergency department of the largest governmental hospital in Jordan.

Method

This was a retrospective observational 4-week study. A validated definition of PEs was adopted, and errors were identified by direct observation of all prescriptions. Structured interviews with doctors to assess the causes of errors were conducted within three days of the prescription date; the severity of PEs was rated by a committee.

Main outcome measure

Prescribing errors incidence, types, severity, causes, predictors, pharmacists' interventions accepted by doctors and computer-related errors.

Results

For 1330 patients, 3470 medication orders were recorded. Almost one in five patients had PEs (n = 288, 21.65%), and the total number of medication orders for patients who had errors was 610. The PEs incidence was 12.5% (95% CI 11.4%–3.5% (n = 450/3597)). Analgesics were the most common medications associated with PEs (232/610, 38.03%). The top two types of PEs detected were wrong drug (165/450, 36.6%) and wrong dose (142/450, 31.5%) respectively. Most PEs were clinically significant errors (342/450, 76%). Doctors refused pharmacists' interventions on their orders in 132 (45.8%) prescriptions. The most common cause of errors was poor skills of doctors in electronic prescribing system (266/450, 59%). Predictors of PEs were the following: drug with multiple dosage forms (OR 2.998; 95% CI 1.41–6.34; P = 0.004) and a prescription with polypharmacy (OR 1.685; 95% CI 1.25%–2.26%; P = 0.001).

Conclusion

A national approach for observing, intervening on and correcting PEs is necessary to improve patient safety.

Clinical pharmacy in onco-hematology and bone marrow transplant: A valuable contribution to improving patient safety

INTRODUCTION

It is known that clinical pharmacists intercept prescribing errors and contribute to patient safety in several medical specialties. The aim of this study was to identify, quantify and classify prescribing errors and pharmacist interventions carried out in onco-hematology and bone marrow transplant inpatient units.

METHODS

This was a prospective and quantitative study, conducted from February 2018 to July 2018 in onco-hematology and bone marrow transplant inpatient units of a tertiary teaching hospital in Brazil. A pharmacist detected prescribing errors and performed interventions. The type and incidence of prescribing errors, error severity, type of pharmacist interventions, potential impact of interventions in patient care, and intervention acceptance rates were evaluated.

RESULTS

A total of 1172 prescriptions were evaluated, 9% of them contained errors (total of 135 errors), and the most common error was related to prescribing the wrong dose (31.8%). Wrong dose and omission of drug were the two most frequent errors in onco-hematology, while wrong dose followed by inappropriate dilution were the most frequent in bone marrow transplantation. The pharmacist performed 135 interventions and the most common intervention was related to the treatment regimen (41.5%). Serious errors and very significant pharmacist interventions were the most frequent in both inpatient units. The acceptance rate of pharmacist interventions was high (90%).

CONCLUSIONS

Clinical pharmacy improves patient safety and quality of care in onco-hematology and bone marrow transplant inpatient units.

Economic analysis of the prevalence and clinical and economic burden of medication error in England

OBJECTIVES

To provide national estimates of the number and clinical and economic burden of medication errors in the National Health Service (NHS) in England.

METHODS

We used UK-based prevalence of medication errors (in prescribing, dispensing, administration and monitoring) in primary care, secondary care and care home settings, and associated healthcare resource use, to estimate annual number and burden of errors to the NHS. Burden (healthcare resource use and deaths) was estimated from harm associated with avoidable adverse drug events (ADEs).

RESULTS

We estimated that 237 million medication errors occur at some point in the medication process in England annually, 38.4% occurring in primary care; 72% have little/no potential for harm and 66 million are potentially clinically significant. Prescribing in primary care accounts for 34% of all potentially clinically significant errors. Definitely avoidable ADEs are estimated to cost the NHS £98 462 582 per year, consuming 181 626 bed-days, and causing/contributing to 1708 deaths. This comprises primary care ADEs leading to hospital admission (£83.7 million; causing 627 deaths), and secondary care ADEs leading to longer hospital stay (£14.8 million; causing or contributing to 1081 deaths).

CONCLUSIONS

Ubiquitous medicines use in health care leads unsurprisingly to high numbers of medication errors, although most are not clinically important. There is significant uncertainty around estimates due to the assumption that avoidable ADEs correspond to medication errors, data quality, and lack of data around longer-term impacts of errors. Data linkage between errors and patient outcomes is essential to progress understanding in this area.

Parenteral nutrition: a call to action for harmonization of policies to increase patient safety

Unsafe medication practices and medication errors are leading causes of injury and avoidable harm worldwide and are highest in vulnerable groups. In 2017, the World Health Organization launched the third Medication Without Harm Global Patient Safety Challenge to try to reduce risks related to medical treatment. Parenteral nutrition (PN) is in the unique position that, although licensed products are available from manufacturers, formulas may be prepared ad hoc for first-line use that might not be subject to the same regulatory oversight. Safety issues around PN can arise through lack of harmonization in practices, misinterpretation and product unfamiliarity and can occur at any stage from prescription to preparation to administration. Government legislation and regulation vary considerably, with PN not explicitly handled in many countries. We therefore call on policy leaders in all countries to establish policies that ensure patient safety, and that these include PN along with medicines. The available evidence supports obtaining industry prepared PN as first-line therapy for reasons of safety, primarily, and of cost. If a suitable industry prepared ready-to-use PN is not available, standardized all-in-one PN admixtures should be the next line of care, with individualized PN being reserved for patients whose complex nutritional needs cannot be met using standardized admixtures.

Prevalence and Nature of Medication Errors and Preventable Adverse Drug Events in Paediatric and Neonatal Intensive Care Settings: A Systematic Review

INTRODUCTION

Children admitted to paediatric and neonatal intensive care units may be at high risk from medication errors and preventable adverse drug events.

OBJECTIVE

The objective of this systematic review was to review empirical studies examining the prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care units.

DATA SOURCES

Seven electronic databases were searched between January 2000 and March 2019.

STUDY SELECTION

Quantitative studies that examined medication errors/preventable adverse drug events using direct observation, medication chart review, or a mixture of methods in children ≤ 18 years of age admitted to paediatric or neonatal intensive care units were included.

DATA EXTRACTION

Data on study design, detection method used, rates and types of medication errors/preventable adverse drug events, and medication classes involved were extracted.

RESULTS

Thirty-five unique studies were identified for inclusion. In paediatric intensive care units, the median rate of medication errors was 14.6 per 100 medication orders (interquartile range 5.7-48.8%, n = 3) and between 6.4 and 9.1 per 1000 patient-days (n = 2). In neonatal intensive care units, medication error rates ranged from 4 to 35.1 per 1000 patient-days (n = 2) and from 5.5 to 77.9 per 100 medication orders (n = 2). In both settings, prescribing and medication administration errors were found to be the most common medication errors, with dosing errors the most frequently reported error subtype. Preventable adverse drug event rates were reported in three paediatric intensive care unit studies as 2.3 per 100 patients (n = 1) and 21-29 per 1000 patient-days (n = 2). In neonatal intensive care units, preventable adverse drug event rates from three studies were 0.86 per 1000 doses (n = 1) and 0.47-14.38 per 1000 patient-days (n = 2). Anti-infective agents were commonly involved with medication errors/preventable adverse drug events in both settings.

CONCLUSIONS

Medication errors occur frequently in critically ill children admitted to paediatric and neonatal intensive care units and may lead to patient harm. Important targets such as dosing errors and anti-infective medications were identified to guide the development of remedial interventions.

The Impact of Technology on Prescribing Errors in Pediatric Intensive Care: A Before and After Study

BACKGROUND

Increased use of health information technology (HIT) has been advocated as a medication error reduction strategy. Evidence of its benefits in the pediatric setting remains limited. In 2012, electronic prescribing (ICCA, Philips, United Kingdom) and standard concentration infusions (SCIs)-facilitated by smart-pump technology-were introduced into the pediatric intensive care unit (PICU) of an Irish tertiary-care pediatric hospital.

OBJECTIVE

The aim of this study is to assess the impact of the new technology on the rate and severity of PICU prescribing errors and identify technology-generated errors.

METHODS

A retrospective, before and after study design, was employed. Medication orders were reviewed over 24 weeks distributed across four time periods: preimplementation (Epoch 1); postimplementation of SCIs (Epoch 2); immediate postimplementation of electronic prescribing (Epoch 3); and 1 year postimplementation (Epoch 4). Only orders reviewed by a clinical pharmacist were included. Prespecified definitions, multidisciplinary consensus and validated grading methods were utilized.

RESULTS

A total of 3,356 medication orders for 288 patients were included. Overall error rates were similar in Epoch 1 and 4 (10.2 vs. 9.8%; p = 0.8), but error types differed (p < 0.001). Incomplete and wrong unit errors were eradicated; duplicate orders increased. Dosing errors remained most common. A total of 27% of postimplementation errors were technology-generated. Implementation of SCIs alone was associated with significant reductions in infusion-related prescribing errors (29.0% [Epoch 1] to 14.6% [Epoch 2]; p < 0.001). Further reductions (8.4% [Epoch 4]) were identified after implementation of electronically generated infusion orders. Non-infusion error severity was unchanged (p = 0.13); fewer infusion errors reached the patient (p < 0.01). No errors causing harm were identified.

CONCLUSION

The limitations of electronic prescribing in reducing overall prescribing errors in PICU have been demonstrated. The replacement of weight-based infusions with SCIs was associated with significant reductions in infusion prescribing errors. Technology-generated errors were common, highlighting the need for on-going research on HIT implementation in pediatric settings.

Workload of pharmacists and the performance of pharmacy services

Objective

To evaluate the influence of pharmacists’ dispensing workload (PDW) on pharmacy services as measured by prescription suggestion rate (PSR) and dispensing error rate (DER).

Method

This was an observational study in northern and southern Taiwan’s two largest medical centers, from 2012 to 2018. We calculated monthly PDW as number of prescriptions divided by number of pharmacist working days. We used monthly PSR and DER as outcome indicators for pharmacists’ review and dispensing services, respectively. We used Poisson regression model with generalized estimation equation methods to evaluate the influence of PDW on PSR and DER.

Results

The monthly mean of 463,587 (SD 32,898) prescriptions yielded mean PDW, PSR and DER of 52 (SD 3) prescriptions per pharmacist working days, 30 (SD 7) and 8 (SD 2) per 10,000 prescriptions monthly, respectively. There was significant negative impact of PDW on PSR (adjusted rate ratio, aRR: 0.9786; 95%CI: 0.9744–0.9829) and DER (aRR: 0.9567; 95%CI: 0.9477–0.9658). Stratified analyses by time periods (2012–2015 and 2016–2018) revealed the impact of PDW on PSR to be similar in both periods; but with positive association between PDW and DER in the more recent one (aRR: 1.0086, 95%CI: 1.0003–1.0169).

Conclusions

Reduced pharmacist workload was associated with re-allocation of pharmacy time to provide prescription suggestions and, more recently, decrease dispensing errors. Continuous efforts to maintain appropriate workload for pharmacists are recommended to ensure prescription quality.

Electronic charts do not facilitate the recognition of patient hazards by advanced medical students: A randomized controlled study

Chart review is an important tool to identify patient hazards. Most advanced medical students perform poorly during chart review but can learn how to identify patient hazards context-independently. Many hospitals have implemented electronic health records, which enhance patient safety but also pose challenges. We investigated whether electronic charts impair advanced medical students’ recognition of patient hazards compared with traditional paper charts. Fifth-year medical students were randomized into two equal groups. Both groups attended a lecture on patient hazards and a training session on handling electronic health records. One group reviewed an electronic chart with 12 standardized patient hazards and then reviewed another case in a paper chart; the other group reviewed the charts in reverse order. The two case scenarios (diabetes and gastrointestinal bleeding) were used as the first and second case equally often. After each case, the students were briefed about the patient safety hazards. In total, 78.5% of the students handed in their notes for evaluation. Two blinded raters independently assessed the number of patient hazards addressed in the students’ notes. For the diabetes case, the students identified a median of 4.0 hazards [25%–75% quantiles (Q25–Q75): 2.0–5.5] in the electronic chart and 5.0 hazards (Q25–Q75: 3.0–6.75) in the paper chart (equivalence testing, p = 0.005). For the gastrointestinal bleeding case, the students identified a median of 5.0 hazards (Q25–Q75: 4.0–6.0) in the electronic chart and 5.0 hazards (Q25–Q75: 3.0–6.0) in the paper chart (equivalence testing, p < 0.001). We detected no improvement between the first case [median 5.0 (Q25–Q75: 3.0–6.0)] and second case [median, 5.0 (Q25–Q75: 3.0–6.0); p < 0.001, test for equivalence]. Electronic charts do not seem to facilitate advanced medical students’ recognition of patient hazards during chart review and may impair expertise formation.

Exploring the common prescribing errors that occur in the emergency department

BACKGROUND

Prescribing errors are a subset of medication errors that occur on the forms used to prescribe medicines for patients. On their discharge from the emergency department (ED), many patients are given a prescription form to obtain medicines from their local community pharmacist. On the identification of a prescribing error, the patient is sent back to the ED because the medicine cannot be dispensed.

AIM

To identify the most common prescribing errors on prescriptions returned to one large inner-city ED in South Wales from community pharmacies.

METHOD

Prescriptions that were returned to the ED over a six-week period from September and October 2016 were analysed to determine the types of prescribing errors that occurred and their frequency.

RESULTS

A total of 10,218 patients attended the ED over the six-week period, of which 7,731 patients were seen by a clinician and discharged home. Of these, 322 patients were discharged with a prescription, and 20 (6%) of these patients returned to the ED with a prescribing error that prevented the pharmacist from dispensing the medicines. The most common prescribing error was incorrect or missing prescriber information.

CONCLUSION

This study identified that there was a low rate of prescribing errors in the ED, and this was comparable with the rate of prescribing errors identified in the literature. Common prescribing errors could be mitigated through the introduction of electronic prescribing in the ED.

Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC)

Classifying harm associated with a medication error can be time consuming and labour intensive and limited studies undertake this step. There is no standardised process, and few studies that report harm assessment provide adequate methods to allow for study replication. Studies typically mention that a clinical review panel classified patient harm and provide a reference to a classification tool. Moreover, in many studies it is unclear whether potential or actual harm was classified as studies refer only to ‘error severity’. The tools used to categorise the severity of patient harm vary widely across studies and few have been assessed for inter-rater reliability and criterion validity. In this paper, we describe the systematic process we undertook to synthesise the defining elements and strengths, while mitigating the limitations, of existing harm classification tools to derive the Harm Associated with Medication Error Classification (HAMEC). This new tool provides a harm classification for use across clinical and research settings. The provision of an explicit process for its application and guiding category descriptors are designed to reduce the risk of misclassification and produce results that are comparable across studies. As the World Health Organisation embarks on its international safety challenge of reducing medication-related harm by 50%, accompanying methodological advances are required to measure progress.

Perspectives of future pharmacists on the potential for development and implementation of pharmacist prescribing in Qatar

Background Pharmacists in many developed countries have been granted prescribing authorities under what is known as "non-medical prescribing" or "pharmacist prescribing". However, such prescribing privileges are not available in many developing countries. Objective The objective of this study was to determine the perspectives of future pharmacists (recent pharmacy graduates and pharmacy students) on pharmacist prescribing and its potential implementation in Qatar. Methods A convergent parallel mixed-methods design was used: (1) a cross-sectional survey using a pre-tested questionnaire and; (2) focus group discussions to allow for an in-depth understanding of the issue, with a focus on pharmacists prescribing competencies as well as barriers for its implementation. Main outcome measures Future pharmacists' perspectives and attitudes towards pharmacist prescribing in Qatar. Results The majority of the respondents (94.4%) indicated awareness of the prescribing competency related to selecting treatment options. Furthermore, the majority (92.4%) believed that pharmacists should undergo prescribing training and accreditation before been legally allowed to prescribe, a point that was reiterated in the focus group discussions. Participants generally expressed support for collaborative and supplementary prescribing models when developing prescribing frameworks for Qatar. Four categories emerged under the theme barriers to implementation of pharmacist prescribing: lack of prescribing competency, pharmacist mindset, lack of accessibility to patient records and counseling rooms, and diversity of education and training background. Conclusion The majority of recent pharmacy graduates and students were in favor of pharmacist prescribing been implemented in Qatar. However, a special training program was deemed necessary to qualify pharmacists to prescribe safely and effectively.

Multi-site evaluation of partnered pharmacist medication charting and in-hospital length of stay

AIMS

To undertake a multicentre evaluation of translation of a partnered pharmacist medication charting (PPMC) model in patients admitted to general medical units in public hospitals in the state of Victoria, Australia.

METHODS

Unblinded, prospective cohort study comparing patients before and after the intervention. Conducted in seven public hospitals in Victoria, Australia from 20 June 2016 to 30 June 2017. Patients admitted to general medical units were included in the study. Medication charting by pharmacists using a partnered pharmacist model was compared to traditional medication charting. The primary outcome variable was the length of inpatient hospital stay. Secondary outcome measures were medication errors detected within 24 h of the patients' admission, identified by an independent pharmacist assessor.

RESULTS

A total of 8648 patients were included in the study. Patients who had PPMC had reduced median length of inpatient hospital stay from 4.7 (interquartile range 2.8-8.2) days to 4.2 (interquartile range 2.3-7.5) days (P < 0.001). PPMC was associated with a reduction in the proportion of patients with at least 1 medication error from 66% to 3.6% with a number needed to treat to prevent 1 error of 1.6 (95% confidence interval: 1.57-1.64).

CONCLUSION

Expansion of the partnered pharmacist charting model across multiple organisations was effective and feasible and is recommended for adoption by health services.

Adverse drug reactions in primary care: a scoping review

BACKGROUND

Medication-related adverse events, or adverse drug reactions (ADRs) are harmful events caused by medication. ADRs could have profound effects on the patients' quality of life, as well as creating an increased burden on the healthcare system. ADRs are one of the rising causes of morbidity and mortality internationally, and will continue to be a significant public health issue with the increased complexity in medication, to treat various diseases in an aging society. This scoping review aims to provide a detailed map of the most common adverse drug reactions experienced in primary healthcare setting, the drug classes that are most commonly associated with different levels/types of adverse drug reactions, causes of ADRs, their prevalence and consequences of experiencing ADRs.

METHODS

We systematically reviewed electronic databases Ovid MEDLINE, Embase, CINAHL Plus, Cochrane Central Register of Controlled Trials, PsycINFO and Scopus. In addition, the National Patient Safety Foundation Bibliography and the Agency for Health Care Research and Quality and Patient Safety Net Bibliography were searched. Studies published from 1990 onwards until December 7, 2018 were included as the incidence of reporting drug reactions were not prevalent before 1990. We only include studies published in English.

RESULTS

The final search yielded a total of 19 citations for inclusion published over a 15-year period that primarily focused on investigating the different types of adverse drug reactions in primary healthcare. The most causes of adverse events were related to drug related and allergies. Idiosyncratic adverse reactions were not very commonly reported. The most common adverse drug reactions reported in the studies included in this review were those that are associated with the central nervous system, gastrointestinal system and cardiovascular system. Several classes of medications were reported to be associated with adverse events.

CONCLUSION

This scoping review identified that the most causes of ADRs were drug related and due to allergies. Idiosyncratic adverse reactions were not very commonly reported in the literature. This is mainly because it is hard to predict and these reactions are not associated with drug doses or routes of administration. The most common ADRs reported in the studies included in this review were those that are associated with the central nervous system, gastrointestinal system and cardiovascular system. Several classes of medications were reported to be associated with ADRs.

Factors, influencing medication errors in prehospital care: A retrospective observational study

To determine the frequency of medication errors in prehospital care and to investigate the influencing factors - diagnostic agreement (DA), the medical educational status, the specialty, the approval for emergency medicine of the prehospital emergency physician, the patient age and sex and the time of deployment.We retrospectively reviewed 708 patients from 2013 to 2015, treated by the prehospital emergency physicians of the emergency medical service center Bad Belzig, Germany. The medication appropriateness was determined by a systematic comparison of the administered medication in prehospital deployments with the discharge diagnosis, according to current guidelines. The influencing factors were examined by univariate analysis of medication appropriateness (MA), using the χ, the Mann-Whtiney U and the Welch tests. We calculated a cut-off value with the Youden index to predict absent MA, according to patients age. The significance level was P = .05.MA was absent in 220 of 708 patients (31.1%). In the case of present DA, MA was absent in 103 of 491 patients (20.9%). In the case of absent DA, MA was absent in 117 of 217 patients (53.9%) (P = .01). MA was absent in 82 of 227 patients (36.1%), treated by specialist and in 138 of 481 patients (28.7%), treated by resident physicians (P = .04). The calculated cut-off value to predict absent MA was 75.5 years. MA was absent in 100 of 375 patients (26.7%) of the younger patient age group (≤75.5 years), MA was absent 120 of 333 patients (36.0%) of the older patient age group (>75.5 years) (P = .01). Absent MA showed peak values (46.7%-60%) at night from 3 to 6 AM (P = .01) The other investigated factors had no influence on MA.The correctness of medication as a quality feature in prehospital care shows a necessity for improvement with a proportion of 31.1% medication errors. The correct diagnosis by the prehospital emergency physician and his rapid accumulation of experience had an impact on the correctness of medication in prehospital care. Elderly patients (75+ years) and nighttime prehospital deployments (3-6 AM) were identified as high risk for medication errors by the emergency physicians.

Evaluation of online clinical pharmacology curriculum resources for medical students

Aims

To identify and evaluate clinical pharmacology (CP) online curricular (e‐Learning) resources that are internationally available for medical students.

Methods

Literature searches of Medline, EMBASE and ERIC databases and an online survey of faculty members of international English language medical schools, were used to identify CP e‐Learning resources. Resources that were accessible online in English and aimed to improve the quality of prescribing specific medications were then evaluated using a summary percentage score for comprehensiveness, usability and quality, and for content suitability.

Results

Our literature searches and survey of 252 faculty (40.7% response rate) in 219 medical schools identified 22 and 59 resources respectively. After screening and removing duplicates, 8 eligible resources remained for evaluation. Mean total score was 53% (standard deviation = 13). The Australian National Prescribing Curriculum, ranked highest with a score of 77%, based primarily on very good ratings for usability, quality and suitable content.

Conclusion

Using a novel method and evaluation metric to identify, classify, and rate English language CP e‐Learning resources, the National Prescribing Curriculum was the highest ranked open access resource. Future work is required to implement and evaluate its effectiveness on prescribing competence.

Medication Appropriateness in Prehospital Care

BACKGROUND

The aim of the present study was to determine the medication appropriateness (MA) in prehospital emergency physician deployments according to the hospital discharge diagnosis and to investigate the factors influencing the MA.

METHODS

The MA was determined by a systematic comparison of the administered medication in prehospital emergency physician deployments with the discharge diagnosis in a period of 24 months at the emergency medical services in Bad Belzig. Categorial variables for the specialty, medical educational status, and approval for emergency medicine of prehospital emergency physicians were examined univariate for relations with the MA, using the χ2 test with the significance level of p=0.05.

RESULTS

The MA was present in 69% (n = 488) cases. The MA was present in 64% of cases by specialists and in 71% by resident physicians (p=0.04). The specialty and the approval for emergency medicine of the prehospital emergency physician did not show significant results. MA was present in 46% (n = 100) of cases with incorrect diagnoses, and it was present in 79% (n = 388) of cases with correct diagnoses by the prehospital emergency physician (p=0.01). In cases of missing MA, 224 drugs and 23 different drugs were administered by the prehospital emergency physician.

CONCLUSIONS

The MA in prehospital emergency physician deployments shows a necessity for improvement with 31% medication errors. Incorrect diagnoses by the prehospital emergency physician seem to lead to medication errors in prehospital emergency physician deployments. The necessary standards and guidelines for administration of drugs should be taken into account in educational courses. The wide-ranging emergency medical training and the rapid accumulation of operational experience seem to play a crucial role for correct administration of medication in the prehospital emergency physician deployments.

Prevalence of medical errors in Iran: a systematic review and meta-analysis

BACKGROUND

Medical errors are considered as a major threat to patient safety. To clarify medical errors' status in Iran, a review was conducted to estimate the accurate prevalence of medical errors.

METHODS

A comprehensive search was conducted in international databases (MEDLINE, Scopus and the Web of Science), national databases (SID, Magiran, and Barakat) and Google Scholar search engine. The search was performed without time limitation up to January 2017 using the MeSH terms of Medical "error(s)" and "Iran" in Endnote X5. Article in English and Persian which estimated the prevalence of medical errors in Iran were eligible to be included in this review. The JBI appraisal instrument was used to assess the quality of included studies, by two independent reviewers. The prevalence of medical errors was calculating using random effect model. Stata software was used for data analysis.

RESULTS

In 40 included studies, the most frequent occupational group observed were nursing staff and nursing students (21 studies; 52% of studies). The most reported type of error was medication error (25 studies; 62% of studies, with prevalence ranged from 10 to 80%). University or teaching hospitals (30 studies; 75% of studies) as well as, internal/intensive care wards (10 studies; 25% of studies) were the most frequent hospitals and wards detected. Based on the result of the random effect model, the overall estimated prevalence of medical errors was 50% (95% confidence interval: 0.426, 0.574).

CONCLUSION

Result of the comprehensive literature review of the current studies, found a wide variation in the prevalence of medical errors based on the occupational group, type of error, and health care setting. In this regards, providing enough education to nurses, improvement of patient safety culture and quality of services and attention to special wards, especially in teaching hospitals are suggested.

Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation

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.

Clinical Validity Assessment of Integrated Dose Range Checking Tool in a Tertiary Care Hospital Using an Electronic Health Information System

Background/purpose: The electronic clinical decision support system (CDSS) is mainly used to assist health care providers in their decision-making process. CDSS includes the dose range checking (DRC) tool. This study aims to evaluate the clinical validity of the DRC tool and compare it to the institutional Formulary and Drug Therapy Guide powered by Lexi-Comp. Methods: This retrospective study analyzed DRC alerts in the inpatient setting. Alerts were assessed for their clinical validity when compared to recommendations of the institution's formulary. Relevant data regarding patient demographics and characteristics were collected. A sample size of 3000 DRC alerts was needed to give a margin of error of 1% (using normal approximation to binomial distribution gives 30.26/3000 = 1%). Results: In our cohort, 1659 (55%) of the DRC alerts were generated for adult patients. A total of 1557 (52%) of all medication-related DRC alerts recommended renal dose adjustments, while 708 (24%) needed hepatic dose adjustments. Majority of alerts, 2844 (95%), were clinically invalid. A total of 2892 (96%) alerts were overridden by prescribers. In 997 (33%) cases, there was an overdose relative to the recommended dose, and in 1572 (52%) there was underdosing. Residents were more likely to accept the DRC alerts compared with other health provider categories (P < .001). Conclusion: Using DRC as a clinical decision support tool with minimal integration yielded serious clinically invalid recommendations. This could increase medication-prescribing errors and lead to alert fatigue in electronic health care systems.

Development and Evaluation of a Clinical Decision Support System to Improve Medication Safety

BACKGROUND

Clinical decision support systems (CDSSs) are a good strategy for preventing medication errors and reducing the incidence and severity of adverse drug events (ADEs). However, these systems are not very effective and are subject to multiple limitations that prevent their implementation in clinical practice.

OBJECTIVES

The objective of this study was to evaluate the effectiveness of an advanced CDSS, HIGEA, which generates alerts based on predefined clinical rules to identify patients at risk of an ADE.

METHODS

A multidisciplinary team defined the system and the clinical rules focusing on medication errors commonly encountered in clinical practice. Four intervention programs were defined: (1) dose adjustment in renal impairment; (2) adjustment of anticoagulation/antiplatelet therapy; (3) detection of biochemical/hematologic toxicities; and (4) therapeutic drug monitoring. We performed a 6-month observational prospective study to analyze the effectiveness of these clinical rules by calculating the positive predictive value (PPV).

RESULTS

The team defined 211 clinical rules. During the study period, HIGEA generated 1,086 alerts (8.9 alerts per working day), which were reviewed by pharmacists. Fifty-one percent (554/1,086) of alerts generated an intervention to prevent a possible ADE; of these, 66% (368/554) required a documented modification to therapy owing to a real prescription error intercepted. The intervention program that induced the highest number of modifications to therapy was the dose adjustment in renal impairment program (PPV = 0.51), followed by the adjustment of anticoagulation/antiplatelet therapy program (PPV = 0.24). The percentage of accepted interventions was similar in surgical units (68%), medical units (67%), and critical care units (63%).

CONCLUSION

Our study offers evidence that HIGEA is highly effective in preventing potential ADEs at the prescription stage.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Trainee doctors' experiences of common problems in the antibiotic prescribing process: an activity theory analysis of narrative data from UK hospitals

INTRODUCTION

Prescribing antibiotics is an error-prone activity and one of the more challenging responsibilities for doctors in training. The nature and extent of challenges experienced by them at different stages of the antibiotic prescribing process are not well described, meaning that interventions may not target the most problematic areas.

OBJECTIVES

Our aim was to explore doctors in training experiences of common problems in the antibiotic prescribing process using cultural-historical activity theory (CHAT). Our research questions were as follows: What are the intended stages in the antibiotic prescribing process? What are the challenges and where in the prescribing process do these occur?

METHODS

We developed a process model based on how antibiotic prescribing is intended to occur in a 'typical' National Health Service hospital in the UK. The model was first informed by literature and refined through consultation with practising healthcare professionals and medical educators. Then, drawing on CHAT, we analysed 33 doctors in training narratives of their antibiotic prescribing experiences to identify and interpret common problems in the process.

RESULTS

Our analysis revealed five main disturbances commonly occurring during the antibiotic prescribing process: consultation challenges, lack of continuity, process variation, challenges in patient handover and partial loss of object. Our process model, with 31 stages and multiple practitioners, captures the complexity, inconsistency and unpredictability of the process. The model also highlights 'hot spots' in the process, which are the stages that doctors in training are most likely to have difficulty navigating.

CONCLUSIONS

Our study widens the understanding of doctors in training prescribing experiences and development needs regarding the prescribing process. Our process model, identifying the common disturbances and hot spots in the process, can facilitate the development of antibiotic prescribing activities and the optimal design of interventions to support doctors in training.

Medication errors in hospitals in the Middle East: a systematic review of prevalence, nature, severity and contributory factors

PURPOSE

The aim was to critically appraise, synthesise and present the evidence of medication errors amongst hospitalised patients in Middle Eastern countries, specifically prevalence, nature, severity and contributory factors.

METHODS

CINAHL, Embase, Medline, Pubmed and Science Direct were searched for studies published in English from 2000 to March 2018, with no exclusions. Study selection, quality assessment (using adapted STROBE checklists) and data extraction were conducted independently by two reviewers. A narrative approach to data synthesis was adopted; data related to error causation were synthesised according to Reason's Accident Causation model.

RESULTS

Searching yielded 452 articles, which were reduced to 50 following removal of duplicates and screening of titles, abstracts and full-papers. Studies were largely from Iran, Saudi Arabia, Egypt and Jordan. Thirty-two studies quantified errors; definitions of 'medication error' were inconsistent as were approaches to data collection, severity assessment, outcome measures and analysis. Of 13 studies reporting medication errors per 'total number of medication orders'/ 'number of prescriptions', the median across all studies was 10% (IQR 2-35). Twenty-four studies reported contributory factors leading to errors. Synthesis according to Reason's model identified the most common being active failures, largely slips (10 studies); lapses (9) and mistakes (12); error-provoking conditions, particularly lack of knowledge (13) and insufficient staffing levels (13) and latent conditions, commonly heavy workload (9).

CONCLUSION

There is a need to improve the quality and reporting of studies from Middle Eastern countries. A standardised approach to quantifying medication errors' prevalence, severity, outcomes and contributory factors is warranted.

Drug-drug interactions and pharmacists' interventions among psychiatric patients in outpatient clinics of a teaching hospital in Saudi Arabia

Background

Lack of recognition of labeled drug-drug interactions (DDIs) is a type of medication error of particular relevance to the treatment of psychiatric patients. Pharmacists are in a position to detect and address potential DDIs.

Objective

This study aimed to explore pharmacists' role in the identification and management of DDIs among psychiatric patients in psychiatric outpatient clinics of a university-affiliated tertiary care hospital in Riyadh, Saudi Arabia.

Method

This study was a retrospective, cross-sectional medical chart review of patients visiting outpatient psychiatric clinics. It utilized medical records of patients who were taking any psychotropic medications and were prescribed at least one additional drug. The hospital Computerized Physician Order Entry system was used to identify DDIs and determine the pharmacists' interventions. The Beers criteria were applied to detect inappropriate prescribing among older patients.

Results

On average, the pharmacists intervened in 12 out of 213 (5.6%) cases of major or moderate DDIs. Older age, higher number of prescription medications, the severity of DDIs, and the utilization of lithium and anticoagulants were positively associated with the pharmacist undertaking an action.

Conclusion

Future studies should explore the prevalence rate of harmful DDIs among psychiatric patients on a large scale and examine the effectiveness of different pharmacy policies in the detection and management of DDIs.