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

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

Developing Resident-Sensitive Quality Measures: Engaging Stakeholders to Inform Next Steps

OBJECTIVE

Despite the need for quality measures relevant to the work residents complete, few attempts have been made to address this gap. Resident-sensitive quality measures (RSQMs) can help fill this void. This study engaged resident and supervisor stakeholders to develop and inform next steps in creating such measures.

METHODS

Two separate nominal group techniques (NGTs), one with residents and one with faculty and fellow supervisors, were used to generate RSQMs for 3 specific illnesses (asthma, bronchiolitis, and closed head injury) as well as general care for the pediatric emergency department. Two separate Delphi processes were then used to prioritize identified RSQMs. The measures produced by each group were compared side by side, illuminating similarities and differences that were explored through focus groups with residents and supervisors. These focus groups also probed future settings in which to develop RSQMs.

RESULTS

In the NGT and Delphi groups, residents and supervisors placed considerable focus on measures in 3 areas across the illnesses of interest: 1) appropriate medication dosing, 2) documentation, and 3) information provided at patient discharge. Focus groups highlighted hospital medicine and general pediatrics as priority areas for developing future RSQMs but also noted contextual variables that influence the application of similar measures in different settings. Residents and supervisors had both similar as well as unique insights into developing RSQMs.

CONCLUSIONS

This study continues to pave the path forward in developing future RSQMs by exploring specific settings, measures, and stakeholders to consider when undertaking this work.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Effect of a medicines management model on medication-related readmissions in older patients admitted to a medical acute admission unit-A randomized controlled trial

RATIONALE, AIMS, AND OBJECTIVES

Medication-related problems are frequent and can lead to serious adverse events resulting in increased morbidity, mortality, and costs. Medication use in frail older patients is even more complex. The aim of this study was to investigate the effect of a pharmacist-led medicines management model among older patients at admission, during inpatient stay and at discharge on medication-related readmissions.

METHOD

A randomized controlled trial conducted at the acute admission unit in a Danish hospital with acutely admitted medical patients, randomized to either a control group or one of two intervention groups. The intervention consisted of pharmacist-led medication review and patient interview upon admission (intervention ED) or pharmacist-led medication review and patient interview upon admission, medication review during inpatient stay, and medication report and patient counselling at discharge (intervention STAY).

RESULTS

In total, 600 patients were included. The pharmacist identified 920 medication-related problems with 57% of the recommendations accepted by the physician. After 30 days, 25 patients had a medication-related readmission, with no statistical significant difference between the groups on either primary or secondary outcomes.

CONCLUSIONS

This study showed that a clinical pharmacist can be used to identify and solve medication-related problems, but this study did not find any effect on the selected outcomes. The frequency of medication-related readmissions was low, leaving little room for improvement. Future research should consider other study designs or outcome measures.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Objectives

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

Design

A prospective cross-sectional, observational study.

Setting

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

Participants

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

Interventions

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

Main Outcome Measures

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

Results

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

Conclusions

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

Perspectives of healthcare professionals in Qatar on causes of medication errors: A mixed methods study of safety culture

Background

There is a lack of robust, rigorous mixed methods studies of patient safety culture generally and notably those which incorporate behavioural theories of change. The study aimed to quantify and explain key aspects of patient safety culture which were of most concern to healthcare professionals in Qatar.

Methods

A sequential explanatory mixed methods design of a cross-sectional survey followed by focus groups in Hamad Medical Corporation, Qatar. All doctors, nurses and pharmacists were invited to complete the Hospital Survey on Patient Safety Culture (HSOPS). Respondents expressing interest in focus group participation were sampled purposively, and discussions based on survey findings using the Theoretical Domains Framework (TDF) to explain behavioural determinants.

Results

One thousand, six hundred and four questionnaires were received (67.9% nurses, 13.3% doctors, 12.9% pharmacists). HSOPS composites with the lowest levels of positive responses were non-punitive response to errors (24.0% positive) and staffing (36.2%). Specific TDF determinants potentially associated with these composites were social/professional role and identity, emotions, and environmental context and resources. Thematic analysis identified issues of doctors relying on pharmacists to correct their errors and being reluctant to alter the prescribing of fellow doctors. There was a lack of recognition of nurses’ roles and frequent policy non-adherence. Stress, workload and lack of staff at key times were perceived to be major contributors to errors.

Conclusions

This study has quantified areas of concern relating to patient safety culture in Qatar and suggested important behavioural determinants. Rather than focusing on changing behaviour at the individual practitioner level, action may be required at the organisational strategic level to review policies, structures (including resource allocation and distribution) and processes which aim to promote patient safety culture.

Near Misses in Financial Trading: Skills for Capturing and Averting Error

OBJECTIVE

The aims of this study were (a) to determine whether near-miss incidents in financial trading contain information on the operator skills and systems that detect and prevent near misses and the patterns and trends revealed by these data and (b) to explore if particular operator skills and systems are found as important for avoiding particular types of error on the trading floor.

BACKGROUND

In this study, we examine a cohort of near-miss incidents collected from a financial trading organization using the Financial Incident Analysis System and report on the nontechnical skills and systems that are used to detect and prevent error in this domain.

METHOD

One thousand near-miss incidents are analyzed using distribution, mean, chi-square, and associative analysis to describe the data; reliability is provided.

RESULTS

Slips/lapses (52%) and human-computer interface problems (21%) often occur alone and are the main contributors to error causation, whereas the prevention of error is largely a result of teamwork (65%) and situation awareness (46%) skills. No matter the cause of error, situation awareness and teamwork skills are used most often to detect and prevent the error.

CONCLUSION

Situation awareness and teamwork skills appear universally important as a "last line" of defense for capturing error, and data from incident-monitoring systems can be analyzed in a fashion more consistent with a "Safety-II" approach.

APPLICATION

This research provides data for ameliorating risk within financial trading organizations, with implications for future risk management programs and regulation.

Understanding the causes of prescribing errors from a behavioural perspective

INTRODUCTION

While many attempts have been made to reduce prescribing errors (PEs), they persist. PE is not in itself a behaviour, but a consequence of a prescribing behaviour. Interventions aimed at prescribers should focus on understanding prescribers' behaviours.

OBJECTIVES

The aim of this study was to use the capability, opportunity, motivation - behaviour (COM-B) model to explore the behaviours that could have caused PEs made by senior doctors in a speciality paediatric inpatient ward.

METHODS

A qualitative approach was used to investigate prescribers' behaviours in a 26-bed paediatric oncology ward. Error data were collected over a two-month period and were presented during focus groups with prescribers, which were audio-recorded and transcribed verbatim. Thematic analysis was used to identify contributory factors to errors, which was used to identify sources of behaviours using the COM-B model.

RESULTS

Behaviours related to prescribers' capabilities were: prescribers' improper use of the software because of insufficient skills, and prescribers' inability to prescribe correctly because of lack of knowledge. Behaviours related to opportunities in the environment were: prescribers' inability to make an informed decision because of poor access to patient information, inability to properly complete a task because of heavy workload and interruption, and having to re-check doses frequently because of frequent change in patients' weight and surface area. Those related to motivation were: prescribers unquestioningly following recommendations and not communicating with other specialists because they over-trusted them or feared a negative reaction, and prescribers inability to complete a task because of other competing and preferable tasks at the same time.

CONCLUSION

Employing COM-B helped in identifying causes of PEs from a new perspective. Future work could focus on mapping identified sources of behaviour and errors against appropriate intervention functions and policies in order to design more successful interventions.

Clinical pharmacist interventions in managing drug-related problems in hospitalized patients with neurological diseases

Background Drug-related problems (DRPs) are common in hospitalized patients with neurological diseases. Clinical pharmacy services could minimize drug-related harm and improve patient care. Objective To identify common DRPs in neurology and document clinical pharmacists' medication-related interventions. Setting The wards and intensive care unit of the Department of Neurology at Assiut University Hospital. Method Prospective study of clinical pharmacists' interventions during the routine care work of reviewing patients medical charts over a period of 6 months from January to June 2017. Main outcome measure The frequency and severity of DRPs and clinical pharmacists' recommendations. Results Out of 1421 reviewed medications charts, a total of 414 DRPs were detected for 285 admitted patients. The most common DRPs were drug selection problems (36.7%) and dosing errors (27.5%). The majority of DRPs (71.7%) were categorized as causing no patient harm. Clinical pharmacists provided recommendations for the detected problems that ranged from drug monitoring to stop and starting new medicines. About 90% of pharmacists' interventions were accepted by physicians. Poisson regression of factors that may influence the frequency of DRPs revealed significant associations of patient age (p = 0.03) and the number of comorbid diseases (p = 0.01). Conclusions Prescribing errors in neurology inpatient are likely to occur. Clinical pharmacists' interventions assisted in early detection of drug problems and prevention of the consequent patient harms.

Simulated medication errors: A means of evaluating healthcare professionals' knowledge and understanding of medication safety

OBJECTIVE

To determine multi-disciplinary perceptions of the clinical significance of medication errors (MEs), the responsible health professional(s), the contributing factors and potential preventive strategies.

METHODS

The five simulated ME cases represented errors from five wards at a children's hospital in Australia. Pre-determined answers for each case were developed through consensus among the researchers. The root cause analysis (RCA) was undertaken via a questionnaire disseminated to physicians, nurses and pharmacists at the study hospital to seek their opinions on the ME cases. Agreement model between the participants and pre-determined responses regarding the contributing factors was conducted using general estimating equation (GEE) analysis.

RESULTS

Of the 111 RCA questionnaires distributed, 25 were returned. The majority (93%) of respondents rated the significance of the MEs as either 'moderate' or 'life-threatening'. Furthermore, they correctly identified two contributing factors relevant to all cases: dismissal of policies/procedures or guidelines (90%) and human resources issues (87%). GEE analysis revealed varied agreement patterns across the contributing factors. Suggested prevention strategies focused on policy and procedures, staffing and supervision, and communication.

CONCLUSION

Simulated case studies had potential use to seek front-line healthcare professionals' understanding of the clinical significance and contributing factors to MEs, along with preventive measures.

Frequency and Nature of Medication Errors and Adverse Drug Events in Mental Health Hospitals: a Systematic Review

INTRODUCTION

Little is known about the frequency and nature of medication errors (MEs) and adverse drug events (ADEs) that occur in mental health hospitals.

OBJECTIVES

This systematic review aims to provide an up-to-date and critical appraisal of the epidemiology and nature of MEs and ADEs in this setting.

METHOD

Ten electronic databases were searched, including MEDLINE, Embase, CINAHL, International Pharmaceutical Abstracts, PsycINFO, Scopus, British Nursing Index, ASSIA, Web of Science, and Cochrane Database of Systematic Reviews (1999 to October 2016). Studies that examined the rate of MEs or ADEs in mental health hospitals were included, and quality appraisal of the included studies was conducted.

RESULT

In total, 20 studies were identified. The rate of MEs ranged from 10.6 to 17.5 per 1000 patient-days (n = 2) and of ADEs from 10.0 to 42.0 per 1000 patient-days (n = 2) with 13.0-17.3% of ADEs found to be preventable. ADEs were rated as clinically significant (66.0-71.0%), serious (28.0-31.0%), or life threatening (1.4-2.0%). Prescribing errors occurred in 4.5-6.3% of newly written or omitted prescription items (n = 3); dispensing errors occurred in 4.6% of opportunities for error (n = 1) and in 8.8% of patients (n = 1); and medication administration errors occurred in 3.3-48.0% of opportunities for error (n = 5). MEs and ADEs were frequently associated with psychotropics, with atypical antipsychotic drugs commonly involved. Variability in study setting and data collection methods limited direct comparisons between studies.

CONCLUSION

Medication errors occur frequently in mental health hospitals and are associated with risk of patient harm. Effective interventions are needed to target these events and improve patient safety.

Use of mobile devices and medication errors in acute care: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to synthesize the best available evidence on the effects of healthcare providers using mobile devices at any stage of medication provision on medication errors in acute care settings. Provision of medication includes prescribing, dispensing or administrating medicine in the acute care setting.

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

Aims

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

Methods

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

Results

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

Conclusions

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

Learning from the design, development and implementation of the Medication Safety Thermometer

Quality issue

Approximately 10% of patients are harmed by healthcare, and of this harm 15% is thought to be medication related. Despite this, medication safety data used for improvement purposes are not often routinely collected by healthcare organizations over time.

Initial assessment

A need for a prospective medication safety measurement tool was identified.

Choice of solution

The aim was to develop a tool to allow measurement and aid improvement of medication safety over time. The methodology used for the National Health Service (NHS) Safety Thermometer was identified as an approach. The resulting tool was named the ‘Medication Safety Thermometer’.

Implementation

The development of the Medication Safety Thermometer was facilitated by a multidisciplinary steering group using a Plan, Do, Study, Act (PDSA) method. Alpha and beta testing occurred over a period of 9 months. The tool was officially launched in October 2013 and continued to be improved until May 2016 using ongoing user feedback.

Evaluation

Feedback was gained through paper and online forms, and was discussed at regular steering group meetings. This resulted in 16 versions of the tool. The tool is now used nationally, with over 230 000 patients surveyed in over 100 NHS organizations. Data from these organizations are openly accessible on a dedicated website.

Lessons learned

Measuring harm from medication errors is complex and requires steps to measure individual errors, triggers of harm and actual harm. PDSA methodology can be effectively used to develop measurement systems. Measurement at the point of care is beneficial and a multidisciplinary approach is vital.

Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review

Background

Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear.

Objective

The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals.

Methods

We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented.

Results

Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5–20.1%), while adverse drug events causing admission were reported in 2.8% (0.7–6.4%) of patients but it was reported that a median of 43.5% (20.0–47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0–0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8–72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5–50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge/training) and environmental factors, such as workplace distraction and high workload.

Conclusion

Medication errors in the African healthcare setting are relatively common, and the impact of adverse drug events is substantial but many are preventable. This review supports the design and implementation of preventative strategies targeting the most likely contributing factors.

Electronic supplementary material

The online version of this article (10.1007/s40801-017-0125-6) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact assessment of an automated drug-dispensing system in a tertiary hospital

OBJECTIVE

To evaluate the costs and patient safety of a pilot implementation of an automated dispensing cabinet in a critical care unit of a private tertiary hospital in São Paulo/Brazil.

METHODS

This study considered pre- (January-August 2013) and post- (October 2013-October 2014) intervention periods. We considered the time and cost of personnel, number of adverse events, audit adjustments to patient bills, and urgent requests and returns of medications to the central pharmacy. Costs were evaluated based on a 5-year analytical horizon and are reported in Brazilian Reals (R$) and US dollars (USD).

RESULTS

The observed decrease in the mean number of events reported with regard to the automated drug-dispensing system between pre- and post-implementation periods was not significant. Importantly, the numbers are small, which limits the power of the mean comparative analysis between the two periods. A reduction in work time was observed among the nurses and administrative assistants, whereas pharmacist assistants showed an increased work load that resulted in an overall 6.5 hours of work saved/day and a reduction of R$ 33,598 (USD 14,444) during the first year. The initial investment (R$ 206,065; USD 88,592) would have been paid off in 5 years considering only personnel savings. Other findings included significant reductions of audit adjustments to patient hospital bills and urgent requests and returns of medications to the central pharmacy.

CONCLUSIONS

Evidence of the positive impact of this technology on personnel time and costs and on other outcomes of interest is important for decision making by health managers.

Prescribing errors intercepted by pharmacist intervention in care of patients hospitalised with breast and gynaecological cancer at a Brazilian teaching hospital

Oncologic inpatients often require multiple drug therapy. They may be at higher risk of experiencing prescribing errors, which pharmacist interventions may help to avoid. This study aimed to evaluate the types of prescribing errors, pharmaceutical interventions and differences in clinical significance, in prescriptions for hospitalised patients with breast and gynaecological cancer. A cross-sectional, prospective study was conducted at the oncology ward of a clinic specialised in breast and gynaecology cancer. A clinical pharmacist analysed prescriptions, identified errors, performed interventions and classified clinical significance. A total of 1,874 prescriptions of 248 patients were evaluated; 11.5% prescriptions were involved at least in one prescribing error, totalising 283 errors. The most common error was unsafe medication due to drug interaction (89[31.4%]). Drugs for the alimentary tract and metabolism, and nervous system were the most involved in errors with statistical association (p = .0246 and p = .0002 respectively). Of the 294 interventions, 73.5% were accepted. The clinical significance of prescribing errors and interventions were classified as significant and very significant respectively. The pharmacist interventions obtained a good acceptance rate and impact significantly, avoiding prescribing errors classified as significant.

Prescriber response to computerized drug alerts for electronic prescriptions among hospitalized patients

BACKGROUND

Clinical decision support systems (CDSS) reduce prescription errors, but their effectiveness is reduced by high alert rates, "alert fatigue", and indiscriminate rejection.

OBJECTIVES

To compare acceptance rates of alerts generated by the SafeRx^® prescription CDSS among different alert types and departments in a tertiary care hospital, identify factors associated with alert acceptance, and determine whether alert overrides were justified.

METHODS

In a retrospective study, we compared acceptance rates of all prescription alerts generated in 2013 in 18 departments of Israel's largest tertiary care center. In a prospective study in 2 internal medicine departments, we collected data on factors potentially associated with alert override, and an expert panel evaluated the justification for each overridden alert. We used multivariate analyses to examine the association between patient and physician-related factors and alert acceptance.

RESULTS

In the retrospective study, of 390,841 prescriptions, 37.1% triggered at least one alert, 5.3% of which were accepted. Acceptance rates ranged from 7.9% for excessive dose alerts to 4.0% for duplicate drug and major drug-drug interactions alerts (p<0.001). In the prospective study, common reasons for alert overriding included "irrelevance to the specific condition" and "medication previously tolerated by the patient". Weekend shifts (incident rate ratio [IRR]=1.50 [95% CI, 1.01-2.22]) and a specific department (IRR=1.87 [1.23-2.87]) were associated with higher alert acceptance, while night shift (IRR=0.47 [0.26-0.85]) was associated with alert override. Most alert overrides (88.6%) were judged justified.

CONCLUSIONS

The vast majority of SafeRx^® alerts are overridden, and overriding is justified in most cases. Minimizing the number of alerts is essential to reduce the likelihood of developing "alert fatigue". Our findings may inform a rational, department-specific approach for alert silencing.

Assessing the association between thinking dispositions and clinical error

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Learning from errors: analysis of medication order voiding in CPOE systems

OBJECTIVE

Medication order voiding allows clinicians to indicate that an existing order was placed in error. We explored whether the order voiding function could be used to record and study medication ordering errors.

MATERIALS AND METHODS

We examined medication orders from an academic medical center for a 6-year period (2006-2011; n  = 5 804 150). We categorized orders based on status (void, not void) and clinician-provided reasons for voiding. We used multivariable logistic regression to investigate the association between order voiding and clinician, patient, and order characteristics. We conducted chart reviews on a random sample of voided orders ( n  = 198) to investigate the rate of medication ordering errors among voided orders, and the accuracy of clinician-provided reasons for voiding.

RESULTS

We found that 0.49% of all orders were voided. Order voiding was associated with clinician type (physician, pharmacist, nurse, student, other) and order type (inpatient, prescription, home medications by history). An estimated 70 ± 10% of voided orders were due to medication ordering errors. Clinician-provided reasons for voiding were reasonably predictive of the actual cause of error for duplicate orders (72%), but not for other reasons.

DISCUSSION AND CONCLUSION

Medication safety initiatives require availability of error data to create repositories for learning and training. The voiding function is available in several electronic health record systems, so order voiding could provide a low-effort mechanism for self-reporting of medication ordering errors. Additional clinician training could help increase the quality of such reporting.

Pattern of medication errors among inpatients in a resource-limited hospital setting

PURPOSE OF THE STUDY

There are limited studies on medication errors in South Asian and South East Asian regions. To bridge this gap, we assessed prescribing errors and selected medicine administration errors among inpatients, and the level of acknowledgement of prescribing errors by specialist physicians in a resource-limited hospital setting.

STUDY DESIGN

The study was conducted in two medical wards of a hospital in Sri Lanka. Prescribing errors were identified among medicines prescribed in the latest prescription of randomly selected inpatients. Medical notes, medication histories and clinic notes were information sources. Consistency of medicine administration according to prescribing instructions was assessed by matching prescriptions with medicine charts. The level of acknowledgement of prescribing errors by specialist physicians of study wards was assessed by questionnaire.

RESULTS

Prescriptions of 400 inpatients (2182 medicines) were analysed. There were 115 patients with at least one medication error. Among the 400 patients, 32.5% (n=130) were prescribing errors. The most frequent types of prescribing errors were 'wrong frequency' (10.3%, n=41), 'prescribing duplications' (10%, n=40), 'prescribing unacceptable medicine combinations' (6%, n=24) and 'medicine omissions' (4.3%, n=17). Medicine charts of 10 patients were inconsistent with prescribing instructions. Wrong medicine administration frequencies were common. The levels of acknowledgment of prescribing errors by the two specialist physicians were 75.5% and 90.9%, respectively.

CONCLUSIONS

Prescribing and medicine administration errors happen in resource-limited hospitals. Errors related to dosing regimen and failing to document medicines prescribed or administered to patients in their records were particularly high.

Validation of the assessment of risk tool: patient prioritisation technology for clinical pharmacist interventions

Background

Adverse drug events (ADEs) pose a heavy burden on health systems worldwide. The assessment of risk tool (ART) was developed to help prioritise hospitalised patients for interventions such as medication reconciliation (MR) and review, and to reduce potential ADEs from unintentional medication discrepancies and prescribing errors.

Aim

To validate ART, and to determine which of the selected 25 flags were significantly associated with risk of unintentional medication discrepancies and prescribing errors.

Method

This was a prospective observational study of 247 admissions to two medical teams in a New Zealand hospital. Study pharmacists undertook MR and review for all eligible admissions over 5 months. A Kruskal-Wallis test was used to determine differences in numbers of unintentional medication discrepancies and prescribing errors, followed by generalised linear modelling, to find the estimated ratio of the mean number of unintentional medication discrepancies between the three ART groups. In part 2 of the study, using multivariable logistic regression, combinations of flags significantly associated with risk were identified.

Results

Significant differences in the number of unintentional medication discrepancieswere found between the ART risk groups (p<0.0001, Kruskal-Wallis test). Patients in the high-risk group had a significantly greater number of unintentional medication discrepancies than those in the medium- and low-risk groups. There were no significant differences in prescribing errors between the ART risk groups (p=0.08, Kruskal-Wallis test). Flags significantly associated with risk, included 'more than eight admission medications', OR=3.7 (95% CI 2.2 to 6.4) and 'readmission within 30 days', OR=6.8 (95% CI 3.0 to 15.2), p<0.0001.

Conclusion

ART was effective for prioritising patients for interventions such as MR.

Definition of variables required for comprehensive description of drug dosage and clinical pharmacokinetics

PURPOSE

Electronic clinical decision support systems (CDSS) require drug information that can be processed by computers. The goal of this project was to determine and evaluate a compilation of variables that comprehensively capture the information contained in the summary of product characteristic (SmPC) and unequivocally describe the drug, its dosage options, and clinical pharmacokinetics.

METHODS

An expert panel defined and structured a set of variables and drafted a guideline to extract and enter information on dosage and clinical pharmacokinetics from textual SmPCs as published by the European Medicines Agency (EMA). The set of variables was iteratively revised and evaluated by data extraction and variable allocation of roughly 7% of all centrally approved drugs.

RESULTS

The information contained in the SmPC was allocated to three information clusters consisting of 260 variables. The cluster "drug characterization" specifies the nature of the drug. The cluster "dosage" provides information on approved drug dosages and defines corresponding specific conditions. The cluster "clinical pharmacokinetics" includes pharmacokinetic parameters of relevance for dosing in clinical practice. A first evaluation demonstrated that, despite the complexity of the current free text SmPCs, dosage and pharmacokinetic information can be reliably extracted from the SmPCs and comprehensively described by a limited set of variables.

CONCLUSION

By proposing a compilation of variables well describing drug dosage and clinical pharmacokinetics, the project represents a step forward towards the development of a comprehensive database system serving as information source for sophisticated CDSS.

Factors influencing the degree of physician-pharmacist collaboration within Iraqi public healthcare settings

OBJECTIVES

Medication safety and effectiveness can be improved through interprofessional collaboration. The goals of this study were to measure the degree of physician-pharmacist collaboration within Iraqi governmental healthcare settings and to investigate factors influencing this collaboration.

METHODS

This cross-sectional study was conducted in Al-Najaf Province using the Collaborative Working Relationship Model and Physician-Pharmacist Collaborative Instrument (PPCI). Four pharmacists distributed paper surveys with a 7-point Likert scale to a convenience sample of physicians and pharmacists working in seven public hospitals and two outpatient clinics. The questionnaire (in English) covered individual (demographics, practising years and academic affiliation), context (practice setting) and PPCI characteristics (trustworthiness, role specification and relationship initiation) in addition to collaborative care items: one for pharmacists and one for physicians. Separate multiple regressions were used to assess the association of the factors with collaborative care for physicians and for pharmacists.

KEY FINDINGS

Seventy-seven physicians and 86 pharmacists returned usable surveys (81.5% response rate). The majority of physicians were male (84%), while the majority of pharmacists were female (58%). The mean age of the physicians was (37.99 years) older than that of the pharmacists (30.35 years). The physicians had a longer period of practice (11.32 years) than pharmacists (5.45 years). Most (90%) of the providers were practising in hospitals. Pharmacist academic affiliation was significantly associated with collaborative care. The pharmacist and physician regressions indicated significant (P < 0.05) associations between collaborative care and two PPCI domains (role specification and relationship initiation for physicians; role specification and trustworthiness for pharmacists).

CONCLUSIONS

This study focused on physician-pharmacist collaboration within hospitals, and it was the first study measuring interprofessional collaboration in Iraq. The results showed there is physician-pharmacist collaboration within Iraqi hospitals and exchange characteristics had significant influence on this collaboration.

Future perspectives on nonmedical prescribing

Many countries have implemented nonmedical prescribing (NMP) and many others are scoping prescribing practices with a view to developing NMP. This paper provides a future perspective on NMP in light of findings of an umbrella review of aspects of NMP. This is followed by coverage of the Scottish Government strategy of pharmacist prescribing and finally, consideration of two key challenges. The review identified seven systematic reviews of influences on prescribing decision-making, processes of prescribing, and barriers and facilitators to implementation. Decision making was reported as complex with many, and often conflicting, influences. Facilitators of NMP included perceived improved patient care and professional autonomy, while barriers included lack of defined roles and resource pressures. Three systematic reviews explored patient outcomes that were noted to be equivalent or better to physician prescribing. In particular, a Cochrane review of 46 studies of clinical, patient-reported, and resource-use outcomes of NMP compared with medical prescribing showed positive intervention-group effects. Despite positive findings, authors highlighted high bias, poor definition and description of 'prescribing' and the 'prescribing process' and difficulty in separating NMP effects from the contributions of other healthcare team members. While evidence of benefit and safety is essential to inform practice, for NMP to be implemented and sustained on a large scale, there needs to be clear commitment at the highest level. The approach being taken by the Scottish Government to pharmacist prescribing implementation may inform developments in other professions and countries. The vision is that by 2023, all pharmacists providing pharmaceutical care will be pharmacist-independent prescribers. There are, however, challenges to implementing NMP into working practice; two key challenges are the need for sustainable models of care and evaluation research. These challenges could be met by considering the theoretical basis for implementation, and robust and rigorous evaluation.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Influences on prescribing decision-making among non-medical prescribers in the United Kingdom: systematic review

BACKGROUND

Suitably qualified non-medical healthcare professionals may now prescribe medicines. Prescribing decision-making can be complex and challenging; a number of influences have been identified among medical prescribers but little appears to be known about influences among non-medical prescribers (NMPs).

OBJECTIVE

To critically appraise, synthesize and present evidence on the influences on prescribing decision-making among supplementary and independent NMPs in the UK.

METHODS

The systematic review included all studies between 2003 and June 2013. Included studies researched the prescribing decision-making of supplementary and independent NMPs practising in the UK; all primary and secondary study designs were considered. Studies were assessed for quality and data extracted independently by two researchers, and findings synthesized using a narrative approach.

RESULTS

Following duplicates exclusion, 886 titles, 349 abstracts and 40 full studies were screened. Thirty-seven were excluded leaving three for quality assessment and data extraction. While all studies reported aspects of prescribing decision-making, this was not the primary research aim for any. Studies were carried out in primary care almost exclusively among nurse prescribers (n = 67). Complex influences were evident such as experience in the role, the use of evidence-based guidelines and peer support and encouragement from doctors; these helped participants to feel more knowledgeable and confident about their prescribing decisions. Opposing influences included prioritization of experience and concern about complications over evidence base, and peer conflict.

CONCLUSION

While there is a limited evidence base on NMPs' prescribing decision-making, it appears that this is complex with NMPs influenced by many and often opposing factors.

Essential competencies in prescribing: A first european cross-sectional study among 895 final-year medical students

European medical students should have acquired adequate prescribing competencies before graduation, but it is not known whether this is the case. In this international multicenter study, we evaluated the essential knowledge, skills, and attitudes in clinical pharmacology and therapeutics (CPT) of final‐year medical students across Europe. In a cross‐sectional design, 26 medical schools from 17 European countries were asked to administer a standardized assessment and questionnaire to 50 final‐year students. Although there were differences between schools, our results show an overall lack of essential prescribing competencies among final‐year students in Europe. Students had a poor knowledge of drug interactions and contraindications, and chose inappropriate therapies for common diseases or made prescribing errors. Our results suggest that undergraduate teaching in CPT is inadequate in many European schools, leading to incompetent prescribers and potentially unsafe patient care. A European core curriculum with clear learning outcomes and assessments should be urgently developed.

An assessment of the basic medication safety practices in Khartoum State hospitals

Purpose

To assess the presence of medication safety practices in Khartoum State hospitals.

Methods

A previously used questionnaire was used to evaluate medication safety practices. The main practices evaluated were the presence of a medication safety committee and error-reporting system, look-alike sound-alike (LASA) medications list, control of concentrated electrolyte solutions, care transitions, information technology, drug information and other medication safety practices. The primary investigator visited a stratified sample from all the three cities that comprise Khartoum State and interviewed the pharmacy supervisor of each hospital. Descriptive statistics were performed using SPSS V.22.

Results

A total of 41 senior pharmacists or pharmacy supervisors from 41 hospitals were interviewed. Only 2% of the hospitals had a list of LASA medications and 5% had a list of error-prone abbreviations. Only 5% of the hospitals had a medication safety committee, and none of the hospitals had a medication safety officer. None of the hospitals involved pharmacists in obtaining medication histories. Concentrated electrolytes were available in the floor stock in 67% of the hospitals. Although 24% of the hospitals used a computer system in their pharmacy to enter prescriptions, none of these hospitals required entry of patient allergies before entering a drug order.

Conclusions

Most of the hospitals in Khartoum State did not implement basic medication safety practices. Therefore, the Ministry of Health in Sudan should enforce laws and regulations making implementation of medication safety practices mandatory to ensure patient safety.

Prescribing errors in two ICU wards in a large teaching hospital in Iran

BACKGROUND

Despite efforts to improve the patients' safety, medical errors especially prescription errors can lead to morbidity and mortality in patients. The present study was conducted to assess the prescription errors in the intensive care units (ICU) in Shiraz, Southwest of Iran.

METHODS

We reviewed the all recorded orders in the two ICU wards of the Shiraz largest hospital in the south of Iran. Data were collected from the two wards and hospital archive using a structured checklist. Descriptive statistics, Chi-square and logistic regression tests were used to analyze the data.

RESULTS

Among the 2230 recorded prescriptions for 40 hospitalized patients, 387 prescribed orders (251 in the General ICU and 136 in the Central ICU) had at least one error which occurred in the three months of the study. The study revealed that illegible orders have the highest error frequency in the two wards. The mean prescription error in the two ICU wards was 17.3 (0.19 errors in the General and 0.14 errors in The Central ICU, respectively). Lack of drug dosage was more than that in the larger wards (P = 0.037); moreover, illegible order and mistaken dosage were more in smaller wards (OR 1.84, CI = 1.18-2.86 and OR 2.55, CI = 1.08-6.00, P = 0.007 and P = 0.031, respectively).

CONCLUSION

The rate of prescription errors in ICU wards was high and it was higher in crowded wards. Illegible orders were the majority of important errors in prescriptions. In the majority of orders, physicians did not write the drug form and drug dose which could be potentially harmful to patients. It is recommended that a computerized physician order should be used because it can decrease prescription errors.

Impact of the implementation of vasoactive drug protocols on safety and efficacy in the treatment of critically ill patients

WHAT IS KNOWN AND OBJECTIVE

The correct management of high-alert medications is a priority issue in expert recommendations for improving the clinical safety of patients. Objectives were to assess the impact of the implementation of vasoactive drug (VAD) protocols on safety and efficacy in the treatment of critically ill patients.

METHODS

A prospective before-and-after study on the implementation of different VAD protocols, comparing medication errors (MEs) rates, mean intensive care unit (ICU) stay, mean blood pressure (MAP), heart rate (HR) and oxygen saturation.

RESULTS AND DISCUSSION

The study included 432 patients. There was a statistically significant decrease in prescribing errors (55·9%), validation errors (68·1%) and medication administration records (MAR) errors (78·8%). No differences were found between the two phases in ICU stay, MAP, HR and oxygen saturation.

WHAT IS NEW AND CONCLUSION

Implementation of protocols decreases variability in clinical practice, reduces the incidence of MEs and maintains the effectiveness of VAD therapy in critically ill patients.

A needs assessment study for optimising prescribing practice in secondary care junior doctors: the Antibiotic Prescribing Education among Doctors (APED)

Background

Appropriate antimicrobial prescribing is essential for patient care, yet up to half of antimicrobial prescriptions written in the UK are sub-optimal. Improving prescriber education has recently been promoted as a mechanism to optimise antimicrobial use, but identification of key learning objectives to facilitate this is so far lacking. Using qualitative methods we investigated junior doctor knowledge, attitudes, and behaviours around antimicrobial prescribing to identify key areas to address in future educational programmes.

Methods

A cross-sectional survey of qualified doctors in training in West London was undertaken exploring antimicrobial prescribing practices and educational needs.

Results

Among 140 junior doctors from 5 London hospitals, a third (34 %) reported prescribing primarily unsupervised, and two thirds (67 %) reported difficulties obtaining prescribing support outside of hours. 20 % stated not feeling confident in writing an antimicrobial prescription, but confidence was increased through having confirmatory diagnostic results (24) and obtaining advice from a senior doctor (26 %); whether this senior was from their own specialty, or an infection-specialist, varied significantly (p < 0.01) by experience. Only a small percentage (5–13 %; depending on number of years post-qualification) of participants stated their previous antimicrobial education was effective. 60 % of those in their first year post qualification reported wanting further education in antimicrobial prescribing, rising to 74 % among more experienced junior doctors. Specific areas of educational need identified were (i) principles of antimicrobial prescribing, (ii) diagnosis of infections, (iii) clinical review of patients with infections, (iv) prescribing in the context of antimicrobial resistance, and (v) laboratory testing and test results.

Conclusions

A significant proportion of junior doctors report lone prescribing of antimicrobials in the context of low self-perceived confidence and knowledge in this field, and frequent difficulty in accessing help when necessary. Innovative training, targeting five specific areas identified through this needs assessment, is urgently needed by junior doctors practising in secondary care.

Patients' perception of types of errors in palliative care - results from a qualitative interview study

Background

Medical errors have been recognized as a relevant public health concern and research efforts to improve patient safety have increased. In palliative care, however, studies on errors are rare and mainly focus on quantitative measures. We aimed to explore how palliative care patients perceive and think about errors in palliative care and to generate an understanding of patients’ perception of errors in that specialty.

Methods

A semistructured qualitative interview study was conducted with patients who had received at least 1 week of palliative care in an inpatient or outpatient setting. All interviews were transcribed verbatim and analysed according to qualitative content analysis.

Results

Twelve patients from two centers were interviewed (7 women, median age 63.5 years, range 22–90 years). Eleven patients suffered from a malignancy. Days in palliative care ranged from 10 to 180 days (median 28 days). 96 categories emerged which were summed up under 11 umbrella terms definition, difference, type, cause, consequence, meaning, recognition, handling, prevention, person causing and affected person. A deductive model was developed assigning umbrella terms to error-theory-based factor levels (definition, type and process-related factors). 23 categories for type of error were identified, including 12 categories that can be considered as palliative care specific. On the level of process-related factors 3 palliative care specific categories emerged (recognition, meaning and consequence of errors).

Conclusion

From the patients’ perspective, there are some aspects of errors that could be considered as specific to palliative care. As the results of our study suggest, these palliative care-specific aspects seem to be very important from the patients’ point of view and should receive further investigation. Moreover, the findings of this study can serve as a guide to further assess single aspects or categories of errors in palliative care in future research.

[Pharmacist rounds on geriatric wards : Assessment of 1 year of pharmaceutical counseling]

BACKGROUND

Older patients suffer more often from drug-induced complications.

OBJECTIVE

What are the precise recommendations pharmacists can give to geriatricians?

MATERIAL AND METHODS

Two pharmacists conducted clinical rounds on 2 geriatric wards over a period of 54 weeks. Protocols of conspicuous medications for geriatric patients were analyzed and suggestions were made.

RESULTS

Particularly frequent were the questionable medical indications for proton pump inhibitors, allopurinol, pregabalin and gabapentin. Adjustment of the dosage of heparin and its analogs to impaired renal function of patients was often lacking. This was also occasionally the case for metformin, some antibiotics and simvastatin. There were several interactions of drug combinations with a high risk for QT prolongation. The inhibition of resorption of bisphosphonates and L‑thyroxin by the simultaneous intake of magnesium and calcium seemed to be probable. Furthermore, it was noticed that for some medications for patients treated by percutaneous endoscopic gastrostomy (PRG) administration by feeding tubes was not possible and combinations of different eye drops which should not be applied simultaneously but at delayed time intervals.

CONCLUSION

An additional medication-related visit provides an interventional option for avoidance of medication errors.

Methods to reduce prescribing errors in elderly patients with multimorbidity

The global population of multimorbid older people is growing steadily. Multimorbidity is the principal cause of complex polypharmacy, which in turn is the prime risk factor for inappropriate prescribing and adverse drug reactions and events. Those who prescribe for older frailer multimorbid people are particularly prone to committing prescribing errors of various kinds. The causes of prescribing errors in this patient population are multifaceted and complex, including prescribers' lack of knowledge of aging physiology, geriatric medicine, and geriatric pharmacotherapy, overprescribing that frequently leads to major polypharmacy, inappropriate prescribing, and inappropriate drug omission. This review examines the various ways of minimizing prescribing errors in multimorbid older people. The role of education in physician prescribers and clinical pharmacists, the use of implicit and explicit prescribing criteria designed to improve medication appropriateness in older people, and the application of information and communication-technology systems to minimize errors are discussed in detail. Although evidence to support any single intervention to prevent prescribing errors in multimorbid elderly people is inconclusive or lacking, published data support focused prescriber education in geriatric pharmacotherapy, routine application of STOPP/START (screening tool of older people's prescriptions/screening tool to alert to right treatment) criteria for potentially inappropriate prescribing, electronic prescribing, and close liaison between clinical pharmacists and physicians in relation to structured medication review and reconciliation. Carrying out a structured medication review aimed at optimizing pharmacotherapy in this vulnerable patient population presents a major challenge. Another challenge is to design, build, validate, and test by clinical trials suitably versatile and efficient software engines that can reliably and swiftly perform complex medication reviews in older multimorbid people. The European Union-funded SENATOR and OPERAM clinical trials commencing in 2016 will examine the impact of customized software engines in reducing medication-related morbidity, avoidable excess cost, and rehospitalization in older multimorbid people.

The impact of a medication review with follow-up service on hospital admissions in aged polypharmacy patients

AIMS

The aims were to assess the impact of a medication review with follow-up (MRF) service provided in community pharmacy to aged polypharmacy patients on the number of medication-related hospital admissions and to estimate the effect on hospital costs.

METHODS

This was a sub-analysis of a cluster randomized controlled trials carried out in 178 community pharmacies in Spain. Pharmacies in the intervention group (IG) provided a comprehensive medication review during 6 months. Pharmacists in the comparison group (CG) delivered usual care. For the purposes of this sub-analysis, an expert panel of three internal medicine specialists screened the hospitalizations occurring during the main study, in order to identify medication-related hospitalizations. Inter-rater reliability was measured using Fleiss's kappa. Hospital costs were calculated using diagnosis related groups.

RESULTS

One thousand four hundred and three patients were included in the main study and they had 83 hospitalizations. Forty-two hospitalizations (50.6%) were medicine-related, with a substantial level of agreement among the experts (kappa = 0.65, 95% CI 0.52, 0.78, P < 0.01). The number of medication-related hospitalizations was significantly lower in patients receiving MRF (IG 11, GC 31, P = 0.042). The probability of being hospitalized was 3.7 times higher in the CG (odds ratio 3.7, 95% CI 1.2, 11.3, P = 0.021). Costs for a medicine-related hospitalization were €6672. Medication-related hospitalization costs were lower for patients receiving MRF [IG: €94 (SD 917); CG: €301 (SD 2102); 95% CI 35.9, 378.0, P = 0.018].

CONCLUSION

MRF provided by community pharmacists might be an effective strategy to balance the assurance of the benefit from medications and the avoidance of medication-related hospitalizations in aged patients using polypharmacy.

Prevalence, Nature, Severity and Risk Factors for Prescribing Errors in Hospital Inpatients: Prospective Study in 20 UK Hospitals

Introduction

It has been suggested that doctors in their first year of post-graduate training make a disproportionate number of prescribing errors.

Objective

This study aimed to compare the prevalence of prescribing errors made by first-year post-graduate doctors with that of errors by senior doctors and non-medical prescribers and to investigate the predictors of potentially serious prescribing errors.

Methods

Pharmacists in 20 hospitals over 7 prospectively selected days collected data on the number of medication orders checked, the grade of prescriber and details of any prescribing errors. Logistic regression models (adjusted for clustering by hospital) identified factors predicting the likelihood of prescribing erroneously and the severity of prescribing errors.

Results

Pharmacists reviewed 26,019 patients and 124,260 medication orders; 11,235 prescribing errors were detected in 10,986 orders. The mean error rate was 8.8 % (95 % confidence interval [CI] 8.6–9.1) errors per 100 medication orders. Rates of errors for all doctors in training were significantly higher than rates for medical consultants. Doctors who were 1 year (odds ratio [OR] 2.13; 95 % CI 1.80–2.52) or 2 years in training (OR 2.23; 95 % CI 1.89–2.65) were more than twice as likely to prescribe erroneously. Prescribing errors were 70 % (OR 1.70; 95 % CI 1.61–1.80) more likely to occur at the time of hospital admission than when medication orders were issued during the hospital stay. No significant differences in severity of error were observed between grades of prescriber. Potentially serious errors were more likely to be associated with prescriptions for parenteral administration, especially for cardiovascular or endocrine disorders.

Conclusion

The problem of prescribing errors in hospitals is substantial and not solely a problem of the most junior medical prescribers, particularly for those errors most likely to cause significant patient harm. Interventions are needed to target these high-risk errors by all grades of staff and hence improve patient safety.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-015-0320-x) contains supplementary material, which is available to authorized users.

Partnered pharmacist charting on admission in the General Medical and Emergency Short-stay Unit - a cluster-randomised controlled trial in patients with complex medication regimens

WHAT IS KNOWN AND OBJECTIVE

Patients admitted to general medical units and emergency short-stay units are often complex with multiple comorbidities, polypharmacy and at risk for drug-related problems associated with increased morbidity and mortality. The aim of this study was to evaluate the effectiveness of a partnered pharmacist charting model completed at the time of admission to prevent medication errors.

METHODS

We conducted an unblinded cluster randomized controlled trial comparing partnered pharmacist charting to standard medical charting among patients admitted to general medical units and emergency short-stay units with complex medication regimens or polypharmacy. This trial was conducted at an adult major referral hospital in metropolitan Melbourne, Australia, with an annual emergency department attendance of approximately 60 000 patients. The evaluation included patients' medication charts written in the period of 16 March 2015 to 27 July 2015. Patients randomized to the intervention were managed using the partnered pharmacist charting model. The primary outcome variable was a medication error identified by an independent assessor within 24 h of admission, who was not part of the patient's admission process.

RESULTS

Of the 473 patients who received standard medical staff charting during the study period, 372 (78·7%) had at least one medication error identified compared to 15 patients (3·7%) on the partnered pharmacist charting arm (P < 0·001). The relative risk of an error with standard medical charting was 21·4 (95% CI: 13·0-35·0) with a number needed to treat (NNT) to prevent one error of 1·3 (95% CI: 1·3-1·4), and the relative risk of a high or extreme risk error with standard medical charting was 150·9 (95% CI: 21·2-1072·9) with a NNT to prevent one high or extreme error of 2·7 (95% CI 2·4-3·1).

WHAT IS NEW AND CONCLUSION

Partnering between medical staff and pharmacists to jointly chart initial medications on admission significantly reduced inpatient medication errors (including errors of high and extreme risk) among general medical and emergency short-stay patients with complex medication regimens or polypharmacy.