The determinants of antimicrobial prescribing among hospital doctors in England: a framework to inform tailored stewardship interventions

AIM

Little is known about the determinants of antimicrobial prescribing behaviour (APB), how they vary between hospital prescribers or the mechanism by which interventions are effective. Yet, interventions based on a sound theoretical understanding of APB are more likely to be successful in changing outcomes. This study sought to quantify the potential determinants of APB among hospital doctors in south-west England.

METHODS

This multicentre, quantitative study employed a closed answer questionnaire to garner hospital doctors' views on factors influencing their APB. Underlying constructs within the data were identified using exploratory factor analysis and subsequent pairwise comparisons assessed for variance between groups of prescribers.

RESULTS

The questionnaire was completed by 301 doctors across four centres (response rate ≥ 74%) and three key factors were identified: autonomy, guidelines adherence and antibiotic awareness. The internal consistency for the questionnaire scale and for each factor subscale was good (α ≥ 0.7). Subgroup analysis identified significant differences between groups of prescribers: autonomy scores increased with grade until at the specialist trainee level (P ≤ 0.009), foundation doctors scored higher for guidelines adherence than consultants (P = 0.004) and specialist trainees (P = 0.003) and United Kingdom trained doctors scored higher than those trained abroad for antibiotic awareness (P < 0.0005). Scores did not vary significantly between doctors from different centres.

CONCLUSION

Autonomy, guidelines adherence and antibiotic awareness were identified as important factors relevant to APB, which vary with experience and training. A theoretical framework is offered to facilitate development of more effective, tailored interventions to change APBs.

Developing consensus on hospital prescribing indicators of potential harm for infants and children

AIMS

The aim of the study was to develop a list of hospital based paediatric prescribing indicators that can be used to assess the impact of electronic prescribing or clinical decision support tools on paediatric prescribing errors.

METHODS

Two rounds of an electronic consensus method (eDelphi) were carried out with 21 expert panellists from the UK. Panellists were asked to score each prescribing indicator for its likelihood of occurrence and severity of outcome should the error occur. The scores were combined to produce a risk score and a median score for each indicator calculated. The degree of consensus between panellists was defined as the proportion that gave a risk score in the same category as the median. Indicators were included if a consensus of 80% or higher was achieved and were in the high risk categories.

RESULTS

Each of the 21 panellists completed an exploratory round and two rounds of scoring. This identified 41 paediatric prescribing indicators with a high risk rating and greater than 80% consensus. The most common error type within the indicators was wrong dose (n = 19) and the most common drug classes were antimicrobials (n = 10) and cardiovascular (n = 7).

CONCLUSIONS

A set of 41 paediatric prescribing indicators describing potential harm for the hospital setting has been identified by an expert panel. The indicators provide a standardized method of evaluation of prescribing data on both paper and electronic systems. They can also be used to assess implementation of clinical decision support systems or other quality improvement initiatives.

The effectiveness of interventions designed to reduce medication administration errors: a synthesis of findings from systematic reviews

AIM

The aim of this overview was to examine the effectiveness of interventions designed to improve patient safety by reducing medication administration errors using data from systematic reviews.

BACKGROUND

Medication administration errors remain unacceptably high despite the introduction of a range of interventions aimed at enhancing patient safety. Systematic reviews of strategies designed to improve medication safety report contradictory findings. A critical appraisal and synthesis of these findings are, therefore, warranted.

METHODS

A comprehensive three-step search strategy was employed to search across 10 electronic databases. Two reviewers independently examined the methodological rigour and scientific quality of included systematic reviews using the Assessment of Multiple Systematic Reviews protocol.

RESULTS

Sixteen systematic reviews were eligible for inclusion. Evidence suggest that multifaceted approaches involving a combination education and risk management strategies and the use of bar code technology are effective in reducing medication errors.

CONCLUSION

More research is needed to determine the benefits of routine double-checking of medications during administration by nurses, outcomes of self-administration of medications by capable patients, and associations between interruptions and medications errors.

IMPLICATIONS FOR NURSING MANAGEMENT

Medication-related incidents must be captured in a way that facilitates meaningful categorisation including contributing factors, potential and actual/risk of harm and contextual information on the incident.

A systematic review of the prevalence and incidence of prescribing errors with high-risk medicines in hospitals

WHAT IS KNOWN

Prescribing errors are the most common type of error in the medication use process. However, there is a paucity of literature regarding the prevalence or incidence of prescribing errors in high-risk medicines (HRMs). HRMs bear a heightened risk of causing significant patient harm when they are used in error.

OBJECTIVE

The aim of this research was to systematically investigate the literature regarding the prevalence and incidence of prescribing errors in HRMs in inpatient settings.

METHODS

A search strategy was developed based on four categories of keywords: prescribing errors, HRMs, hospital inpatients, and prevalence or incidence. All keywords were searched for in Medline, Embase, Cochrane and the International Pharmaceutical Abstracts. The search was limited to English quantitative studies that reported the incidence or prevalence of prescribing errors by medical prescribers, whether they were seniors or juniors, since 1985.

RESULTS

Of the 3507 records identified, nine studies met the review criteria. The most frequent denominator in the included studies was medication orders, in eight studies, ranged from 0·24 to 89·6 errors per 100 orders of HRMs. Two studies reported 107 and 218 errors per 100 admissions prescribed HRMs, and one study reported 27·2 errors per 100 prescriptions with a HRM. The incidence of prescribing errors could not be calculated.

WHAT IS NEW AND CONCLUSION

The prevalence of prescribing errors in HRMs in the inpatient setting has a very wide range that reflects the different data collection methods used within the included studies. Future studies in prescribing errors should use standardized approaches to enable comparison.

Nonmedical prescribing: where are we now?

Nonmedical prescribing has been allowed in the United Kingdom (UK) since 1992. Its development over the past 24 years has been marked by changes in legislation, enabling the progression towards independent prescribing for nurses, pharmacists and a range of allied health professionals. Although the UK has led the way regarding the introduction of nonmedical prescribing, it is now seen in a number of other Western-European and Anglophone countries although the models of application vary widely between countries. The programme of study to become a nonmedical prescriber (NMP) within the UK is rigorous, and involves a combination of taught curricula and practice-based learning. Prescribing is a complex skill that is high risk and error prone, with many influencing factors. Literature reports regarding the impact of nonmedical prescribing are sparse, with the majority of prescribing research tending to focus instead on prescribing by doctors. The impact of nonmedical prescribing however is important to evaluate, and can be carried out from several perspectives. This review takes a brief look back at the history of nonmedical prescribing, and compares this with the international situation. It also describes the processes required to qualify as a NMP in the UK, potential influences on nonmedical prescribing and the impact of nonmedical prescribing on patient opinions and outcomes and the opinions of doctors and other healthcare professionals.

Adding value through pharmacy validation: a safety and cost perspective

RATIONALE, AIMS AND OBJECTIVES

Prescribing errors (PE) are frequent, cause significant harm to patients and prove costly. Few studies demonstrate the impact of pharmacist interventions. The objectives of this study were to characterize the severity and cost of the potential outcome of PE that pharmacists can prevent and to develop an economic analysis.

METHOD

We performed a non-randomized, prospective, observational study of all prescriptions made to adult patients admitted to a 1300-bed tertiary teaching hospital in Madrid (Spain) by means of a computerized physician order entry tool combined with a clinical decision support system. We analysed PE intercepted through the pharmacist validation process between January and June 2013. An independent team determined the severity of the potential adverse drug event (ADE) and the probability of causing an ADE (PAE). We estimated the cost avoidance and performed an economic analysis. A kappa statistic was used to verify inter-observer agreement.

RESULTS

484 PE were intercepted: 36.2% of PE were classified as being of minor severity, 59.1% as moderate and 4.7% as serious. The most common type of moderate-serious PE found was excessive dose (30%, 94/309), followed by insufficient dose (20%, 62/309), and omission (19%, 58/309). The most frequent families of drugs involved in moderate-serious PE were antineoplastic agents (22.3%, 69/309) and antimicrobials (17.2%, 53/309). The PAE was higher than 40% in 49% of PE. We estimated a cost avoidance of €291,422 and a return on investment of €1.7 for each €1 spent on a pharmacist's salary. The overall inter-rater agreement for the participants was moderate for severity (κ = 0.57; P <0.005) and strong for the PAE (κ = 0.77; P <0.005).

CONCLUSIONS

Pharmacists add important value in preventing PE, and their interventions are financially beneficial for the institution.

A collaborative evaluation of pharmacy interventions in the care of inpatients in community hospitals

Objectives

To quantify medication-related errors, in particular prescribing errors, identified by pharmacists and assess their potential impact on inpatients in community hospitals.

Methods

Pharmacists recorded all interventions to optimise medication for community hospital inpatients over 14 days in November 2013. Interventions were subsequently classified by type (prescribing error; omitted or delayed drug administration; or attributable to other issues) and rated for potential clinical impact.

Results

15 organisations participated in the study reporting on 4077 medication charts. In total, 52 033 medication orders were screened by pharmacists. A medication-related intervention was made on 1 in 3 charts for one or more medications. A total of 2782 interventions were recorded. The majority were categorised as a prescriber error (67%, 1872/2782). The remainder (33%, 910/2782) were not directly attributable to prescriber error; of these omitted and delayed medicine administration accounted for 11% (298/2782). Of the 1872 interventions classed as prescriber error, a third, if left undetected, might have caused moderate or severe patient harm. The prescribing error rate was 3.6 errors per 100 medication orders.

Conclusions

Pharmacists reported intervening to improve the care provided to over a third of patients in this study. Two-thirds of interventions were in response to prescribing errors, a third of which, if left undetected, could have led to harm. The results suggest that inpatients in community hospitals are subject to prescribing errors at a rate comparable to those seen in acute and mental health hospitals. A clinical pharmacy service is vital to ensure patient safety in community hospitals.

Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A Social Network Analysis and Examination of Prescribing Error Rates

OBJECTIVES

To measure the weekly medication advice-seeking networks of hospital staff, to compare patterns across professional groups, and to examine these in the context of prescribing error rates.

METHOD

A social network analysis was conducted. All 101 staff in 2 wards in a large, academic teaching hospital in Sydney, Australia, were surveyed (response rate, 90%) using a detailed social network questionnaire. The extent of weekly medication advice seeking was measured by density of connections, proportion of reciprocal relationships by reciprocity, number of colleagues to whom each person provided advice by in-degree, and perceptions of amount and impact of advice seeking between physicians and nurses. Data on prescribing error rates from the 2 wards were compared.

RESULTS

Weekly medication advice-seeking networks were sparse (density: 7% ward A and 12% ward B). Information sharing across professional groups was modest, and rates of reciprocation of advice were low (9% ward A, 14% ward B). Pharmacists provided advice to most people, and junior physicians also played central roles. Senior physicians provided medication advice to few people. Many staff perceived that physicians rarely sought advice from nurses when prescribing, but almost all believed that an increase in communication between physicians and nurses about medications would improve patient safety. The medication networks in ward B had higher measures for density, reciprocation, and fewer senior physicians who were isolates. Ward B had a significantly lower rate of both procedural and clinical prescribing errors than ward A (0.63 clinical prescribing errors per admission [95%CI, 0.47-0.79] versus 1.81/ admission [95%CI, 1.49-2.13]).

CONCLUSIONS

Medication advice-seeking networks among staff on hospital wards are limited. Hubs of advice provision include pharmacists, junior physicians, and senior nurses. Senior physicians are poorly integrated into medication advice networks. Strategies to improve the advice-giving networks between senior and junior physicians may be a fruitful area for intervention to improve medication safety. We found that one ward with stronger networks also had a significantly lower prescribing error rate, suggesting a promising area for further investigation.

Development of indicators to assess the quality of medicines reconciliation at hospital admission: an e-Delphi study

OBJECTIVE

The aim of this Delphi study was to examine consensus on the appropriateness of the medicines reconciliation (MR) indicators.

METHODS

Practising hospital pharmacists in UK hospitals conducting MR in hospital wards were invited to participate in the study. Appropriateness was defined using four criteria: clarity, importance, relevance and usefulness. The modified Delphi technique was selected as a structured method to develop consensus. RAND definition for consensus was used. In the second round, feedback on the first round was provided. The study did not require Research Ethics approval.

KEY FINDINGS

Sixty-five hospital pharmacists completed the first round Delphi, and 59 of them completed the second round. Their experience ranged from three to 33 years with an average of 16.6 years. Fifty-five indicators were sent to the panel after the pilot study. Each of the two rounds took approximately 8 weeks to be completed. Forty-one indicators reached consensus to be appropriate. Fourteen indicators did not reach consensus.

CONCLUSIONS

The Delphi technique was very effective for enhancing the panel participation as noticed in their responses both in the first and second rounds. Forty-one indicators achieved consensus as being appropriate to evaluate the MR process. These indicators could be used to assess the process and hence improve the quality of the patient care on hospital admission. The indicators need to be used in practice.

Formalized prescribing error feedback from hospital pharmacists: doctors' attitudes and opinions

Doctors have reported a lack of awareness of their prescribing errors with lack of feedback considered a system failure. This article summarizes the views of hospital doctors about receiving formal prescribing error feedback from ward-based pharmacists.

Cohort study for evaluation of dose omission without justification in a teaching general hospital in Bahia, Brazil

OBJECTIVE

To evaluate the incidence of medication errors due to dose omissions and the reasons for non-administration of medications.

DESIGN

A cohort study blinded to the nursing staff was conducted for 5 consecutive days to evaluate administration of prescribed medications to selected inpatients.

SETTING

A major academic teaching hospital in Brazil.

PARTICIPANTS

Dispensed doses to patients in medical and surgical wards.

MAIN OUTCOME MEASURES

Doses returned to pharmacy were evaluated to identify the rate of dose omission without a justification for omission.

RESULTS

Information was collected from 117 patients in 11 wards and 1119 doses of prescribed medications were monitored. Overall, 238/1119 (21%) dispensed doses were not administered to the patients. Among these 238 doses, 138 (58%) had no justification for not being administered. Failure in the administration of at least 1 dose occurred for 58/117 (49.6%) patients. Surgical wards had significantly more missed doses than that in medical wards (P = 0.048). The daily presence of a pharmacist in the wards was significantly correlated with lower frequency of omission errors (P = 0.019). Nervous system medications were missed more significantly than other medications (P < 0.001). No difference was noted in the omission doses in terms of route of administration.

CONCLUSIONS

High incidence of omission errors occurs in our institution. Factors such as the deficit of nursing staff and clinical pharmacists and a weak medication dispensing system, probably contributed to incidence detected. Blinding nursing staff was essential to improve the sensibility of the method for detecting omission errors.

Initiatives to identify and mitigate medication errors in England

In response to the EU Directive on Pharmacovigilance, the National Health Service (NHS) in England and the Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK have formed a partnership to work together to simplify and increase medication error reporting, improve data report quality, maximise learning and guide practice to minimise harm from medication errors by sharing incident data. This initiative will facilitate implementation of new requirements for medication error reporting and reduce the need for duplicate data entry by frontline staff. The initiative is also intended to provide new types of feedback from the National Reporting and Learning System run by the NHS England and from the Yellow Card Scheme run by the MHRA and to improve learning at the local level by clarifying medication safety roles and identifying key safety contacts to allow better communication between local and national levels. Finally, the partnership has established a new National Medication Safety Network to provide a forum for discussing potential and recognised safety issues, and for identifying trends and actions to improve the safe use of medicines. This article describes the initiative, the structure of which may act as a template for other countries.

Structure, importance and recording of therapeutic information in the medical record: a multicentre observational study

RATIONALE, AIMS AND OBJECTIVES

Structuring the diagnostic section of the medical record (MR) improves diagnosis and communication between doctors. However, little is known about the therapeutic section of the MR. The aim of this study was to gain insight into the extent to which MRs are structured for therapeutic information, to determine which therapeutic data registrars and clinical consultants consider should be recorded in the MR and to what extent registrars record this information themselves.

METHODS

A multicentre observational study was carried out in the internal medicine outpatient clinics of five teaching hospitals in the Netherlands. Preformatted structure, importance and actual recording of therapeutic information was compared with a reference list of 35 therapeutic items based on the WHO Guide to Good Prescribing (e.g. drug name, indication for drug).

RESULTS

The preformatted structure of four paper MRs and one electronic MR was assessed. Eight of the 35 therapeutic items were listed in the paper MRs and 18 items in the electronic MR. Registrars and consultants agreed on the importance of recording most of the therapeutic items in the MR, 25 and 27 out of the 35 items, respectively; however, registrars recorded only 11 of the 35 items in the paper MR and 20 of the 35 items in the electronic MR.

CONCLUSIONS

The structure and content of paper and electronic MRs are not adequate. While both registrars and consultants agree on the importance of recording therapeutic items in the MR, registrars fail to record most of this information in practice. The results of this study can be used as starting point for the discussion regarding the necessity of structured recording of therapeutic information in the MR and its possible benefits with regard to medication safety and training of the new generation of prescribers.

Non-medical prescribing assessment - An evaluation of a nationally agreed multi method approach

In the United Kingdom, legislation permits nurses and allied health professionals to prescribe for patients within their care. Preparation for this role includes learning, teaching and assessment that is embedded in practice, supervised by a designated medical practitioner (DMP) and evidenced in a reflective learning in practice portfolio.

AIM

The objectives were to explore; (1) which assessment in the practice portfolio was ranked most valuable in terms of achieving safe, effective prescribing practice and, (2) whether a practice based assessment (SDEP) was an acceptable alternative to an Observed Simulated Clinical Examination (OSCE).

METHODS

Online surveys were conducted and follow up semi structured telephone interviews were conducted across 5 universities in Scotland with students, DMPs and line managers.

RESULTS

Students ranked the learning log most valuable and DMPs and line managers ranked the SDEP most valuable. Survey and follow up interviews suggested that the portfolio provided the opportunity to develop prescribing skills and knowledge relevant to their specific clinical speciality. There was agreement amongst all participants that clinical assessment in the practice portfolio effectively enable non-medical prescribing students to evidence prescribing competence.

SUMMARY

The novel use of the SDEP and reflective summary offers a viable alternative to an OSCE and was viewed as one of the most valued components of the assessment strategy.

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol

INTRODUCTION

Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review.

METHODS AND ANALYSIS

The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED.

Issues around the Prescription of Half Tablets in Northern Switzerland: The Irrational Case of Quetiapine

BACKGROUND

Prescription of fragmented tablets is useful for individualisation of dose but includes several drawbacks. Although without score lines, the antipsychotic drug quetiapine was in 2011 the most often prescribed 1/2 tablet in discharge prescriptions at the University Hospital in Basel (USB, 671 beds). We aimed at analysing the prescription patterns of split tablets in general and of quetiapine in particular in Switzerland.

METHODS

All orders of community pharmacies for unit-of-use soft pouch blisters placed at Medifilm AG, the leader company in Switzerland for repackaging into pouch blisters, were analysed.

RESULTS

Out of 4,784,999 tablets that were repacked in 2012 in unit-of-use pouch blisters, 8.5% were fragmented, mostly in half (87.6%), and were predominantly psycholeptics (pipamperone 15.8%). Prescription of half quetiapine appears to be a Basel specificity (highest rates of fragments and half quetiapine).

CONCLUSIONS

Prescription of fragmented tablet is frequent. It represents a safety issue for the patient, and a pharmaceutical care issue for the pharmacist. In ambulatory care, the patient's cognitive and physical capacities must be clarified, suitability of the splitting of the tablet must be checked, appropriate aids must be offered, like a pill-splitting device in order to improve accuracy, and safe use of the drug must be ensured.

Development and evaluation of a pocket card to support prescribing by junior doctors in an English hospital

Background Junior doctors do most inpatient prescribing, with a relatively high error rate, and locally had reported finding prescribing very stressful. Objective To develop an intervention to improve Foundation Year 1 (FY1) doctors’ experience of prescribing, and evaluate their satisfaction with the intervention and perceptions of its impact. Methods Based on findings of a focus group and questionnaire, we developed a pocket Dose Reference Card (“Dr-Card”) for use at the point of prescribing. This summarised common drugs and dosing schedules and was distributed to all new FY1 doctors in a London teaching trust. A post-intervention questionnaire explored satisfaction and perceived impact. Results Focus group participants (n = 12) described feeling anxious and time pressured when prescribing; a quick reference resource for commonly prescribed drug doses was suggested. Responses to the exploratory questionnaire reinforced these findings. Following Dr-Card distribution, the post-intervention questionnaire revealed that 29/38 (76 %) doctors were still using it 2 months after distribution and 38/38 (100 %) would recommend ongoing production. Conclusions FY1 doctors reported feeling stressed and time pressured when prescribing; this was perceived to contribute to error. A pocket card presenting common drugs and doses was well-received, perceived to be useful, and recommended for on-going use.

Inter-professional prescribing masterclass for medical students and non-medical prescribing students (nurses and pharmacists): a pilot study

BACKGROUND AND AIMS

Prescribing errors cause significant patient morbidity and mortality. Current legislation allows prescribing by different health professions. Inter-professional collaboration and learning may result in safer prescribing practice. This study aimed to develop, pilot and test the feasibility of a simulated inter-professional prescribing masterclass for non-medical prescribing students, medical students and pharmacists.

METHODS AND RESULTS

A three-scenario, simulated patient session was designed and implemented by an expert panel. Medical students, non-medical prescribing students and pharmacists worked together to formulate and implement evidence-based prescriptions. The Readiness for Inter-professional Learning Score (RIPLS) and a self-efficacy score were administered to the students and the Trust in Physician Score to the simulated patients. Overall, the RIPLS and self-efficacy scores increased. Pharmacists showed the highest rating in the Trust in Physician score. Post masterclass group discussions suggested that the intervention was viewed as a positive educational experience.

CONCLUSION

An inter-professional prescribing masterclass is feasible and acceptable to students. It increases self-efficacy, readiness for inter-professional learning and allows students to learn from, about and with each other. A larger study is warranted and the use of feedback from simulated patients explored further.

Perceived barriers to pharmacist engagement in adverse drug event prevention activities in Ghana using semi-structured interview

Background

Pharmacist involvement in the prevention of medication errors is well documented. One such method, the process by which hospital pharmacists undertake these clinical interventions needs to be described and documented. The perceived barriers to pharmacists succeeding in getting their recommendations accepted could inform future safety strategy development. This study was therefore to trace the typical process involved and explore the perceived barriers to pharmacists’ medication safety efforts.

Methods

This study involved a retrospective evaluation of routine clinical interventions collected at a tertiary hospital in Ghana over 23 months. A sample of pharmacists who had submitted these reports were then interviewed.

Results

The interventions made related to drug therapy changes (76.0 %), monitoring (13.0 %), communication (5.4 %), counselling (5.0 %) and adverse drug events (0.6 %). More than 90 % of interventions were accepted. The results also showed that undertaking clinical interventions by pharmacists followed a sequential order with two interlinked subprocesses: Problem Identification and Problem Handling. In identifying the problem, as much information needed to be gathered, clinical issues identified and then the problems prioritised. During the problem handling stage, detailed assessment was made which led to the development of a pharmaceutical plan. The plan was then implemented and monitored to ensure appropriateness of desired outcomes.

The main barrier mentioned by pharmacist related to the discrepant attitudes of doctors/nurses. The other barriers encountered during these tasks related to workload, and inadequate clinical knowledge. The attitudes were characterised by conflicts and egos resulting from differences in status/authority, responsibilities, and training.

Conclusions

Though the majority of recommendations from pharmacists were accepted, the main barrier to hospital pharmacist engagement in medication error prevention activities related to discrepant attitudes of doctors and nurses. Proper initiation and maintenance of collaborative working relationship in hospitals is desired between the healthcare team members to benefit from the medication safety services of hospital pharmacists.

Incidence and treatment costs attributable to medication errors in hospitalized patients

BACKGROUND

A significant financial burden arises from medication errors that cause direct injury and those without patient harm that represent waste and inefficiency.

OBJECTIVE

To estimate the incidence, types, and causes of medication errors as well as their attributable costs in a hospital setting.

METHODS

For a retrospective case-control study, data were collected for 57,554 patients admitted to two New Jersey (U.S. State) hospitals during 2005-2006 as well as hospital-specific voluntary error reports from these two hospitals for the same period. Medication errors were classified into categories of stage, error type, and proximal cause, and the incidence was estimated. The costs attributable to medication errors were calculated using both the recycled prediction method, and the Blinder-Oaxaca decomposition method after propensity score matching.

RESULTS

Medication errors occurred at a rate of 0.8 per 100 admissions, or 1.6 per 1000 patient days. Most errors occurred at the administration stage of the medication use process. The most frequent types of errors were wrong time, wrong medication, wrong dose, and omission errors. Treatment costs attributable to medication errors were in the range of $8,439 using the Blinder-Oaxaca decomposition method and $8,898 using the recycled prediction method.

CONCLUSIONS

Medication errors are associated with significant additional costs, even without patient harm. Considering the substantial costs associated with adverse drug events, the elimination of medication errors should be further emphasized and promoted, and guidelines should be developed to facilitate this goal.

From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types

A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs) in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason's Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips, one‐third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self‐evaluation tool that would work as a complement to already incident reporting and event and risk analyses.

A Delphi study among internal medicine clinicians to determine which therapeutic information is essential to record in a medical record

Several studies have demonstrated that using a template for recording general and diagnostic information in the medical record (MR) improves the completeness of MR documentation, communication between doctors, and performance of doctors. However, little is known about how therapeutic information should be structured in the MR. The aim of this study was to investigate which specific therapeutic information registrars and consultants in internal medicine consider essential to record in the MR. Therefore, we carried out a 2-round Internet Delphi study. Fifty-nine items were assessed on a 5-point scale; an item was considered important if ≥ 80% of the respondents awarded it a score of 4 or 5. In total, 26 registrars and 30 consultants in internal medicine completed both rounds of the study. Overall, they considered it essential to include information about 11 items in the MR. Subgroup analyses revealed that the registrars considered 8 additional items essential, whereas the consultants considered 1 additional item essential to record. Study findings can be used as a starting point to develop a structured section of the MR for therapeutic information for both paper and electronic MRs. This section should contain at least 11 items considered essential by registrars and clinical consultants in internal medicine.

Examining the attitudes of hospital pharmacists to reporting medication safety incidents using the theory of planned behaviour

OBJECTIVE

To assess the effect of factors within hospital pharmacists' practice on the likelihood of their reporting a medication safety incident.

DESIGN

Theory of planned behaviour (TPB) survey.

SETTING

Twenty-one general and teaching hospitals in the North West of England.

PARTICIPANTS

Two hundred and seventy hospital pharmacists (response rate = 45%).

INTERVENTION

Hospital pharmacists were invited to complete a TPB survey, based on a prescribing error scenario that had resulted in serious patient harm. Multiple regression was used to determine the relative influence of different TPB variables, and participant demographics, on the pharmacists' self-reported intention to report the medication safety incident.

MAIN OUTCOME MEASURES

The TPB variables predicting intention to report: attitude towards behaviour, subjective norm, perceived behavioural control and descriptive norm.

RESULTS

Overall, the hospital pharmacists held strong intentions to report the error, with senior pharmacists being more likely to report. Perceived behavioural control (ease or difficulty of reporting), Descriptive Norms (belief that other pharmacists would report) and Attitudes towards Behaviour (expected benefits of reporting) showed good correlation with, and were statistically significant predictors of, intention to report the error [R = 0.568, R(2) = 0.323, adjusted R(2) = 0.293, P < 0.001].

CONCLUSIONS

This study suggests that efforts to improve medication safety incident reporting by hospital pharmacists should focus on their behavioural and control beliefs about the reporting process. This should include instilling greater confidence about the benefits of reporting and not harming professional relationships with doctors, greater clarity about what/not to report and a simpler reporting system.

Terapêutica medicamentosa para criança em serviço hospitalar de emergência

Resumo Objetivo: Analisar o conhecimento da equipe de enfermagem sobre terapêutica medicamentosa. Métodos: Estudo transversal que incluiu com a participação de 37 profissionais de enfermagem com a utilização de instrumento estruturado e avaliado, com quatro cenários, que envolveram terapêutica medicamentosa. Resultados: Os participantes demonstraram conhecimento uniforme sobre a terapêutica medicamentosa em todos cenários. Porém, foi possível observar diferença estatística significativa (p=0,003) entre os profissionais que trabalham na instituição da pesquisa e que estudam com relação ao terceiro cenário referente à mudança de via de administração de medicação em situações de parada cardiorrespiratória. Conclusão: Os profissionais de enfermagem pesquisados possuem conhecimento sobre a terapêutica medicamentosa direcionada à população pediátrica em situação de urgência.

Partnered medication review and charting between the pharmacist and medical officer in the Emergency Short Stay and General Medicine Unit

OBJECTIVE

A partnered medication review and charting model involving a pharmacist and medical officer was implemented in the Emergency Short Stay Unit and General Medicine Unit of a major tertiary hospital. The aim of the study was to describe the safety and effectiveness of partnered medication charting in this setting.

METHODS

A partnered medication review and charting model was developed. Credentialed pharmacists charted pre-admission medications and venous thromboembolism prophylaxis in collaboration with the admitting medical officer. The pharmacist subsequently had a clinical discussion with the treating nurse regarding the medication management plan for the patient. A prospective audit was undertaken of all patients from the initiation of the service.

RESULTS

A total of 549 patients had medications charted by a pharmacist from the 14th of November 2012 to the 30th of April 2013. A total of 4765 medications were charted by pharmacists with 7 identified errors, corresponding to an error rate of 1.47 per 1000 medications charted.

CONCLUSIONS

Partnered medication review and charting by a pharmacist in the Emergency Short Stay and General Medicine unit is achievable, safe and effective. Benefits from the model extend beyond the pharmacist charting the medications, with clinical value added to the admission process through early collaboration with the medical officer. Further research is required to provide evidence to further support this collaborative model.

A patient-centered research agenda for the care of the acutely ill older patient

Hospitalists and others acute-care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine sponsored the Acute Care of Older Patients Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through 4 steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of 10 research questions in the following areas: advanced-care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training.

Exploring the causes of junior doctors' prescribing mistakes: a qualitative study

AIMS

Prescribing errors are common and can be detrimental to patient care and costly. Junior doctors are more likely than consultants to make a prescribing error, yet there is only limited research into the causes of errors. The aim of this study was to explore the causes of prescribing mistakes made by doctors in their first year post graduation.

METHODS

As part of the EQUIP study, interviews using the critical incident technique were carried out with 30 newly qualified doctors. Participants were asked to discuss in detail any prescribing errors they had made. Participants were purposely sampled across a range of medical schools (18) and hospitals (15). A constant comparison approach was taken to analysis and Reason's model of accident causation was used to present the data.

RESULTS

More than half the errors discussed were prescribing mistakes (errors due to the correct execution of an incorrect plan). Knowledge-based mistakes (KBMs) appeared to arise from poor knowledge of practical aspects of prescribing such as dosing, whereas rule-based mistakes (RBMs) resulted from inappropriate application of knowledge. Multiple error-producing and latent conditions were described by participants for RBMs and KBMs. Poor/absent senior support and a fear of appearing incompetent occurred with KBMs. Following erroneous routines or seniors' orders were major contributory factors in RBMs.

CONCLUSIONS

Although individual factors such as knowledge and expertise played a role in prescribing mistakes, there were many perceived interrelated factors contributing to error. We conclude that multiple interventions are necessary to address these and further research is essential.

Smartphone apps to support hospital prescribing and pharmacology education: a review of current provision

Junior doctors write the majority of hospital prescriptions but many indicate they feel underprepared to assume this responsibility and around 10% of prescriptions contain errors. Medical smartphone apps are now widely used in clinical practice and present an opportunity to provide support to inexperienced prescribers. This study assesses the contemporary range of smartphone apps with prescribing or related content. Six smartphone app stores were searched for apps aimed at the healthcare professional with drug, pharmacology or prescribing content. Three hundred and six apps were identified. 34% appeared to be for use within the clinical environment in order to aid prescribing, 14% out with the clinical setting and 51% of apps were deemed appropriate for both clinical and non-clinical use. Apps with drug reference material, such as textbooks, manuals or medical apps with drug information were the commonest apps found (51%), followed by apps offering drug or infusion rate dose calculation (26%). 68% of apps charged for download, with a mean price of £14.25 per app and a range of £0.62-101.90. A diverse range of pharmacology-themed apps are available and there is further potential for the development of contemporary apps to improve prescribing performance. Personalized app stores may help universities/healthcare organizations offer high quality apps to students to aid in pharmacology education. Users of prescribing apps must be aware of the lack of information regarding the medical expertise of app developers. This will enable them to make informed choices about the use of such apps in their clinical practice.

Redesigning the 'choice architecture' of hospital prescription charts: a mixed methods study incorporating in situ simulation testing

OBJECTIVES

To incorporate behavioural insights into the user-centred design of an inpatient prescription chart (Imperial Drug Chart Evaluation and Adoption Study, IDEAS chart) and to determine whether changes in the content and design of prescription charts could influence prescribing behaviour and reduce prescribing errors.

DESIGN

A mixed-methods approach was taken in the development phase of the project; in situ simulation was used to evaluate the effectiveness of the newly developed IDEAS prescription chart.

SETTING

A London teaching hospital.

INTERVENTIONS/METHODS

A multimodal approach comprising (1) an exploratory phase consisting of chart reviews, focus groups and user insight gathering (2) the iterative design of the IDEAS prescription chart and finally (3) testing of final chart with prescribers using in situ simulation.

RESULTS

Substantial variation was seen between existing inpatient prescription charts used across 15 different UK hospitals. Review of 40 completed prescription charts from one hospital demonstrated a number of frequent prescribing errors including illegibility, and difficulty in identifying prescribers. Insights from focus groups and direct observations were translated into the design of IDEAS chart. In situ simulation testing revealed significant improvements in prescribing on the IDEAS chart compared with the prescription chart currently in use in the study hospital. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber's printed name (163/164 vs 0/174; p<0.0001) and contact number (137/164 vs 55/174; p<0.0001). Antiinfective indication (28/28 vs 17/29; p<0.0001) and duration (26/28 vs 15/29; p<0.0001) were more likely to be completed using the IDEAS chart.

CONCLUSIONS

In a simulated context, the IDEAS prescription chart significantly reduced a number of common prescribing errors including dosing errors and illegibility. Positive behavioural change was seen without prior education or support, suggesting that some common prescription writing errors are potentially rectifiable simply through changes in the content and design of prescription charts.

Prevalence, nature and predictors of prescribing errors in mental health hospitals: a prospective multicentre study

OBJECTIVE

To determine the prevalence, nature and predictors of prescribing errors (PEs) in three mental health hospitals.

SETTING

Inpatient units in three National Health Service (NHS) mental health hospitals in the North West of England.

PARTICIPANTS

Trained clinical pharmacists prospectively recorded the number of PEs in newly written or omitted prescription items screened during their routine work on 10 data collection days. A multidisciplinary panel reviewed PE data using established methods to confirm (1) the presence of a PE, (2) the type of PE and (3) whether errors were clinically relevant and likely to cause harm.

PRIMARY OUTCOME MEASURES

Frequency, nature and predictors of PEs.

RESULTS

Of 4427 screened prescription items, 281 were found to have one or more PEs (error rate 6.3% (95% CI 5.6 to 7.1%)). Multivariate analysis revealed that specialty trainees (OR 1.23 (1.01 to 1.51)) and staff grade psychiatrists (OR 1.50 (1.05 to 2.13)) were more likely to make PEs when compared to foundation year (FY) one doctors, and that specialty trainees and consultant psychiatrists were twice as likely to make clinically relevant PEs (OR 2.61 (2.11 to 3.22) and 2.03 (1.66 to 2.50), respectively) compared to FY one staff. Prescription items screened during the prescription chart rewrite (OR 0.52 (0.33 to 0.82)) or at discharge (OR 0.87 (0.79 to 0.97)) were less likely to be associated with PEs than items assessed during inpatient stay, although they were more likely to be associated with clinically relevant PEs (OR 2.27 (1.72 to 2.99) and 4.23 (3.68 to 4.87), respectively). Prescription items screened at hospital admission were five times more likely (OR 5.39 (2.72 to 10.69)) to be associated with clinically relevant errors than those screened during patient stay.

CONCLUSIONS

PEs may be more common in mental health hospitals than previously reported and important targets to minimise these errors have been identified.

Measuring the severity of prescribing errors: a systematic review

BACKGROUND

Prescribing errors are common. It has been suggested that the severity as well as the frequency of errors should be assessed when measuring prescribing error rates. This would provide more clinically relevant information, and allow more complete evaluation of the effectiveness of interventions designed to reduce errors.

OBJECTIVE

The objective of this systematic review was to describe the tools used to assess prescribing error severity in studies reporting hospital prescribing error rates.

DATA SOURCES

The following databases were searched: MEDLINE, EMBASE, International Pharmaceutical Abstracts, and CINAHL (January 1985-January 2013).

STUDY SELECTION

We included studies that reported the detection and rate of prescribing errors in prescriptions for adult and/or pediatric hospital inpatients, or elaborated on the properties of severity assessment tools used by these studies. Studies not published in English, or that evaluated errors for only one disease or drug class, one route of administration, or one type of prescribing error, were excluded, as were letters and conference abstracts. One reviewer screened all abstracts and obtained complete articles. A second reviewer assessed 10 % of all abstracts and complete articles to check reliability of the screening process.

APPRAISAL

Tools were appraised for country and method of development, whether the tool assessed actual or potential harm, levels of severity assessed, and results of any validity and reliability studies.

RESULTS

Fifty-seven percent of 107 studies measuring prescribing error rates included an assessment of severity. Forty tools were identified that assessed severity, only two of which had acceptable reliability and validity. In general, little information was given on the method of development or ease of use of the tools, although one tool required four reviewers and was thus potentially time consuming.

LIMITATIONS

The review was limited to studies written in English. One of the review authors was also the author of one of the tools, giving a potential source of bias.

CONCLUSION

A wide range of severity assessment tools are used in the literature. Developing a basis of comparison between tools would potentially be helpful in comparing findings across studies. There is a potential need to establish a less time-consuming method of measuring severity of prescribing error, with acceptable international reliability and validity.

The future of community pharmacy practice in South Africa in the light of the proposed new qualification for pharmacists: implications and challenges

Objectives:

Community or retail pharmacies are regarded as one of the most common sources of health services throughout the world. In South Africa, community pharmacies have been providing some primary health care services to clients who could afford to pay. These services included screening, family planning, and emergency care for minor ailments. With the introduction of the new qualification, community pharmacies are poised to become providers of expanded services. This paper describes the contents, the implications and challenges of the new qualification in light with future directions for community pharmacy practice in South Africa. Its purpose is to inform relevant stakeholders in South Africa and those outside South Africa that may pursue similar offerings.

Methods:

Published papers were identified through searches in MEDLINE and Google Scholar using a combination of search terms, namely: ‘community, retail pharmacy, pharmacist/non-medical prescribing, South Africa’. Only articles published in English were considered. In addition, documents from the Ministry of Health of South Africa, the South African Pharmacy Council and curricula materials from schools of pharmacy were also reviewed.

Key Findings:

Laureates of the new qualification will essentially have the right to examine, diagnose, prescribe and monitor the treatment of their clients or patients. In doing so, this expanded function of prescribing for primary healthcare will imply several practice and infrastructural adjustments; and with many challenges laying ahead in need to be addressed.

Conclusions:

In conclusion, the authorized pharmacist prescriber qualification augurs a new era for community pharmacy practice in South Africa. This has many implications and some challenges that need to be managed. The pharmacy profession, academia, legislators and political decision-makers need to work together to resolve outstanding issues in a constructive manner.

Teaching Junior Medical Officers safe and effective prescribing

Medication errors are an iatrogenic threat to patient safety, and recently graduated Junior Medical Officers (JMOs) are a common source of these errors. A ward-based, physician-led, small-group interactive teaching session was developed to improve JMOs competence in prescribing. The ability of JMOs to detect problems in mock medication charts before and after the teaching session was assessed, with the majority improving after the intervention, a result sustained on re-testing later in the year. The teaching sessions were well received by JMOs.

Developing a Platform for Learning from Mistakes: changing the culture of patient safety amongst junior doctors

Junior doctors commonly make mistakes which may compromise patient safety. Despite the recent push by the NHS to encourage a "no blame" culture, mistakes are still viewed as shameful, embarrassing and demoralising events. The current model for learning from mistakes means that junior doctors only learn from their own errors. A survey was designed by the author for all the Foundation Year 1 doctors (FY1s) at Yeovil District Hospital to understand better the culture surrounding mistakes, and the types of mistakes that were being made. Using the results of the survey and the support of senior staff, a "Near misses" session has been introduced for FY1s once a month at which mistakes that have been made are discussed, with a consultant present to facilitate the proceedings. The aims of these sessions are to promote a culture of no blame, feedback information to clinical governance, and share learning experiences. 100% of the FY1s had made a mistake that could compromise patient safety. 63% discussed their mistakes with colleagues, 44% with seniors, and only 13% with their educational supervisor. Barriers to discussing mistakes included shame, embarrassment, fear of judgement, and unapproachable seniors. 94% thought a "Near misses" session would be useful. After the third session 100% of the FY1s agreed that the sessions were useful; 53% had changed their practice as a result of something they learned at the sessions. After discussing errors as a group we have worked with the clinical governance department, enacting strategies to avoid repetition of mistakes. Feedback from the junior doctors has been overwhelmingly positive and we have found these sessions to be a simple, inexpensive, and popular solution to cultural change in our organisation.

Medication reconciliation and prescribing reviews by pharmacy technicians in a geriatric ward

OBJECTIVE

Incomplete medication histories obtained on hospital admission are responsible for more than 25% of prescribing errors. This study aimed to evaluate whether pharmacy technicians can assist hospital physicians' in obtaining medication histories by performing medication reconciliation and prescribing reviews. A secondary aim was to evaluate whether the interventions made by pharmacy technicians could reduce the time spent by the nurses on administration of medications to the patients.

METHODS

This observational study was conducted over a 7 week period in the geriatric ward at Odense University Hospital, Denmark. Two pharmacy technicians conducted medication reconciliation and prescribing reviews at the time of patients' admission to the ward. The reviews were conducted according to standard operating procedures developed by a clinical pharmacist and approved by the Head of the Geriatric Department.

FINDINGS

In total, 629 discrepancies were detected during the conducted medication reconciliations, in average 3 for each patient. About 45% of the prescribing discrepancies were accepted and corrected by the physicians. "Medication omission" was the most frequently detected discrepancy (46% of total). During the prescribing reviews, a total of 860 prescription errors were detected, approximately one per medication review. Almost all of the detected prescription errors were later accepted and/or corrected by the physicians. "Dosage and time interval errors" were the most frequently detected error (48% of total). The time used by nurses for administration of medicines was reduced in the study period.

CONCLUSION

This study suggests that pharmacy technicians can contribute to a substantial reduction in medication discrepancies in acutely admitted patients by performing medication reconciliation and focused medication reviews. Further randomized, controlled studies including a larger number of patients are required to elucidate whether these observations are of significance and of importance for securing patient safety.

Safety of medication use in primary care

BACKGROUND

Medication errors are one of the leading causes of harmin health care. Review and analysis of errors have often emphasized their preventable nature and potential for reoccurrence. Of the few error studies conducted in primary care to date, most have focused on evaluating individual parts of the medicines management system. Studying individual parts of the system does not provide a complete perspective and may further weaken the evidence and undermine interventions.

AIM AND OBJECTIVES

The aim of this review is to estimate the scale of medication errors as a problem across the medicines management system in primary care. Objectives were: To review studies addressing the rates of medication errors, and To identify studies on interventions to prevent medication errors in primary care.

METHODS

A systematic search of the literature was performed in PubMed (MEDLINE), International Pharmaceutical Abstracts (IPA), Embase, PsycINFO, PASCAL, Science Direct, Scopus, Web of Knowledge, and CINAHL PLUS from 1999 to November, 2012. Bibliographies of relevant publications were searched for additional studies.

KEY FINDINGS

Thirty-three studies estimating the incidence of medication errors and thirty-six studies evaluating the impact of error-prevention interventions in primary care were reviewed. This review demonstrated that medication errors are common, with error rates between <1% and >90%, depending on the part of the system studied, and the definitions and methods used. The prescribing stage is the most susceptible, and that the elderly (over 65 years), and children (under 18 years) are more likely to experience significant errors. Individual interventions demonstrated marginal improvements in medication safety when implemented on their own.

CONCLUSION

Targeting the more susceptible population groups and the most dangerous aspects of the system may be a more effective approach to error management and prevention. Co-implementation of existing interventions at points within the system may offer time- and cost-effective options to improving medication safety in primary care.

The causes of prescribing errors in English general practices: a qualitative study

BACKGROUND

Few detailed studies exist of the underlying causes of prescribing errors in the UK.

AIM

To examine the causes of prescribing and monitoring errors in general practice and provide recommendations for how they may be overcome.

DESIGN AND SETTING

Qualitative interview and focus group study with purposive sampling of English general practices.

METHOD

General practice staff from 15 general practices across three PCTs in England participated in a combination of semi-structured interviews (n = 34) and six focus groups (n = 46). Thematic analysis informed by Reason's Accident Causation Model was used.

RESULTS

Seven categories of high-level error-producing conditions were identified: the prescriber, the patient, the team, the working environment, the task, the computer system, and the primary-secondary care interface. These were broken down to reveal various error-producing conditions: the prescriber's therapeutic training, drug knowledge and experience, knowledge of the patient, perception of risk, and their physical and emotional health; the patient's characteristics and the complexity of the individual clinical case; the importance of feeling comfortable within the practice team was highlighted, as well as the safety implications of GPs signing prescriptions generated by nurses when they had not seen the patient for themselves; the working environment with its extensive workload, time pressures, and interruptions; and computer-related issues associated with mis-selecting drugs from electronic pick-lists and overriding alerts were all highlighted as possible causes of prescribing errors and were often interconnected.

CONCLUSION

Complex underlying causes of prescribing and monitoring errors in general practices were highlighted, several of which are amenable to intervention.

The prevalence and nature of prescribing and monitoring errors in English general practice: a retrospective case note review

BACKGROUND

Relatively little is known about prescribing errors in general practice, or the factors associated with error.

AIM

To determine the prevalence and nature of prescribing and monitoring errors in general practices in England.

DESIGN AND SETTING

Retrospective case-note review of unique medication items prescribed over a 12-month period to a 2% random sample of patients. Fifteen general practices across three primary care trusts in England.

METHOD

A total of 6048 unique prescription items prescribed over the previous 12 months for 1777 patients were examined. The data were analysed by mixed effects logistic regression. The main outcome measures were prevalence of prescribing and monitoring errors, and severity of errors, using validated definitions.

RESULTS

Prescribing and/or monitoring errors were detected in 4.9% (296/6048) of all prescription items (95% confidence interval [CI] = 4.4% to 5.5%). The vast majority of errors were of mild to moderate severity, with 0.2% (11/6048) of items having a severe error. After adjusting for covariates, patient-related factors associated with an increased risk of prescribing and/or monitoring errors were: age <15 years (odds ratio [OR] = 1.87, 95% CI = 1.19 to 2.94, P = 0.006) or >64 years (OR = 1.68, 95% CI = 1.04 to 2.73, P = 0.035), and higher numbers of unique medication items prescribed (OR = 1.16, 95% CI = 1.12 to 1.19, P<0.001).

CONCLUSION

Prescribing and monitoring errors are common in English general practice, although severe errors are unusual. Many factors increase the risk of error. Having identified the most common and important errors, and the factors associated with these, strategies to prevent future errors should be developed, based on the study findings.

Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research

Background and objectives

Handover and communication failures are a recognised threat to patient safety. Handover in emergency care is a particularly vulnerable activity owing to the high-risk context and overcrowded conditions. In addition, handover frequently takes place across the boundaries of organisations that have different goals and motivations, and that exhibit different local cultures and behaviours. This study aimed to explore the risks associated with handover failure in the emergency care pathway, and to identify organisational factors that impact on the quality of handover.

Methods

Three NHS emergency care pathways were studied. The study used a qualitative design. Risks were explored in nine focus group-based risk analysis sessions using failure mode and effects analysis (FMEA). A total of 270 handovers between ambulance and the emergency department (ED), and the ED and acute medicine were audio-recorded, transcribed and analysed using conversation analysis. Organisational factors were explored through thematic analysis of semistructured interviews with a purposive convenience sample of 39 staff across the three pathways.

Results

Handover can serve different functions, such as management of capacity and demand, transfer of responsibility and delegation of aspects of care, communication of different types of information, and the prioritisation of patients or highlighting of specific aspects of their care. Many of the identified handover failure modes are linked causally to capacity and patient flow issues. Across the sites, resuscitation handovers lasted between 38 seconds and 4 minutes, handovers for patients with major injuries lasted between 30 seconds and 6 minutes, and referrals to acute medicine lasted between 1 minute and approximately 7 minutes. Only between 1.5% and 5% of handover communication content related to the communication of social issues. Interview participants described a range of tensions inherent in handover that require dynamic trade-offs. These are related to documentation, the verbal communication, the transfer of responsibility and the different goals and motivations that a handover may serve. Participants also described the management of flow of patients and of information across organisational boundaries as one of the most important factors influencing the quality of handover. This includes management of patient flows in and out of departments, the influence of time-related performance targets, and the collaboration between organisations and departments. The two themes are related. The management of patient flow influences the way trade-offs around inner tensions are made, and, on the other hand, one of the goals of handover is ensuring adequate management of patient flows.

Conclusions

The research findings suggest that handover should be understood as a sociotechnical activity embedded in clinical and organisational practice. Capacity, patient flow and national targets, and the quality of handover are intricately related, and should be addressed together. Improvement efforts should focus on providing practitioners with flexibility to make trade-offs in order to resolve tensions inherent in handover. Collaborative holistic system analysis and greater cultural awareness and collaboration across organisations should be pursued.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Nursing students' perspectives of the cause of medication errors

BACKGROUND

Medication errors complicate up to half of inpatient stays and some have very serious consequences. To our knowledge, this is the first qualitative study of Iranian nursing students' perspectives of medication errors.

OBJECTIVES

To describe nursing students' perspectives of the causes of medication errors.

DESIGN

Four focus groups were held with 24 nursing students from 4 different academic semesters in the nursing school in Tehran, between November 2011 and November 2012. Using a qualitative descriptive design, themes and subthemes were identified by content analysis.

RESULTS

Two main themes emerged from the data: "under-developed caring skills in medication management" and "unfinished learning of safe medication management", which was subdivided into "drifting between being worried and being careful", and "contextualising pharmacology education". All respondents felt that their education programmes were leaving them vulnerable to "drug errors" and cited incidents where patient safety had been jeopardised.

CONCLUSION

Nursing curricula need to increase investment in medicines management. If nursing students are to become competent, skilful and safe practitioners, their learning will require extensive support from their academic institutions and clinical mentors.