Safe medication prescribing: training and experience of medical students and housestaff at a large teaching hospital

A mixed-methods needs assessment to identify pharmacology education objectives for emergency medicine residents

Objectives

Medication errors represent a significant threat to patient safety. Pharmacotherapy is one of the 23 Accreditation Council of Graduate Medical Education milestones for emergency medicine, yet there is minimal understanding of what content should be prioritized during training. The study aim was to develop objectives for a patient-safety focused pharmacology curriculum for emergency medicine residents.

Methods

We incorporated data from a de-identified safety event database and survey responses of 30 faculty and clinical pharmacists at a single-site suburban university hospital with 24-hour emergency medicine pharmacists and an annual volume of approximately 70,000. We reviewed the database to quantify types and severity of medication errors over a 5-year period for a total of 370 errors. Anonymous surveys included categorical items that we analyzed with descriptive statistics and short answer questions that underwent thematic analysis by 2 coders. We summarized all data sources to identify curriculum gaps.

Results

Common medication errors reported in our database were wrong dose (43%) and computer order entry errors (14%). Knowledge gaps were medication cost (63%), pregnancy risk information (60%), antibiotic stewardship (53%), interactions (47%), and side effects (47%). Qualitative analysis revealed the need to optimize computer order entry, understand the scope of critical medications, use references, and consult pharmacists. Integration of data suggested specific medications should be covered in curricular efforts, including antibiotics, analgesics, sedatives, and insulin.

Conclusion

We developed objectives of pharmacology topics to prioritize during emergency medicine training to enhance prescribing safety. This study is limited due to its small sample and single institution source of data. Future studies should investigate the impact of pharmacology curriculum on minimizing clinical errors.

Development and evaluation of an online medication safety module for medical students at a rural teaching hospital: the Winchester District Memorial Hospital

Objective

To design, implement and assess an online learning module for third-year and fourth-year medical students addressing medication safety.

Design

This study was a prospective, parallel, open-label, randomised controlled trial with two arms: (1) a control arm in which students were given five articles to read about medication safety, and (2) an intervention arm in which students were given access to an interactive web-based learning module on medication safety. Pretesting and post-testing were done online to evaluate change in medication safety knowledge.

Results

Ten students completed the study in the intervention group (online module) and six students completed the study in the control group. The increase in score obtained on the post-test, relative to the pretest, was 15.4% in the group who completed the online module and 2.0% in the control group (difference=13.4%, 95% CI 0.5% to 26.2%, p=0.04).

Conclusion

Students who completed an online educational tool about medication safety demonstrated a significantly greater increase in knowledge than those who completed a few readings. Online learning modules can be a convenient and effective means of teaching safe prescribing concepts to medical trainees.

Inappropriate use of beta-blockers among medical and dental students at King Saud University, Riyadh

Aim:

Self-medication and inappropriate beta-blocker use have been commonly reported among students. This study aimed to determine the prevalence of inappropriate self-prescription of beta-blockers among medical and dental students.

Methods:

We conducted a cross-sectional study using a validated self-administered questionnaire distributed via online Google document to all undergraduate medical and dental students, including interns, of King Saud University, Riyadh, Saudi Arabia.

Results:

Out of 1,240 emails sent, 885 students (627 [70.8%] medical students and 258 [59.2%] dental students) responded to the survey (response rate, 71.4%). Beta-blockers were used by 198 students (22.4%) during their college years, of which 147 (16.6%) used it ≤5 times. The most common reason of using beta-blockers was to relieve stress and anxiety. The most common sources of information for use were their colleagues/fellow students. Self-prescribed beta-blockers were used by 123 students (13.9%). The usual dose consumed was 20 mg in 84 students (9.5%), while 15 (1.7%) experienced side effects. Although male students used beta-blockers more than females, females used beta-blockers at significantly higher doses (>20 mg). Medical students consumed more beta-blockers than dental students did (33.7% versus 0%, P = 0.001). Students in their senior years continued self-prescription and beta-blocker use longer than their juniors. Continued use was associated with their current academic level, who prescribed the drug, their usual dose, and awareness of complications.

Conclusion:

Two in ten students inappropriately used beta-blockers to relieve their anxiety and stress during examinations, and most of them were self-prescribed.

Frequency, Timing, and Types of Medication Ordering Errors Made by Residents in the Electronic Medical Records Era

OBJECTIVES

To describe associations between resident level of training, timing of medication orders, and the types of inpatient medication ordering errors made by internal medicine residents.

METHODS

This study reviewed all inpatient medication orders placed by internal medicine residents at a tertiary care academic medical center from July 2011 to June 2015. Medication order errors were measured by pharmacists' reporting of an error via the electronic medical record during real-time surveillance of orders. Multivariable regression models were constructed to assess associations between resident training level (postgraduate year [PGY]), medication order timing (time of day and month of year), and rates of medication ordering errors.

RESULTS

Of 1,772,462 medication orders placed by 335 residents, 68,545 (3.9%) triggered a pharmacist intervention in the electronic medical record. Overall and for each PGY level, renal dose monitoring/adjustment was the most common order error (40%). Ordering errors were less frequent during the night and transition periods versus daytime (adjusted odds ratio [aOR] 0.93, 95% confidence interval [CI] 0.91-0.96, and aOR 0.93, 95% CI 0.90-0.95, respectively). Errors were more common in July and August compared with other months (aOR 1.05, 95% CI 1.01-1.09). Compared with PGY2 residents, both PGY1 (aOR 1.06, 95% CI 1.03-1.10), and PGY3 residents (aOR 1.07, 95% CI, 1.03-1.10) were more likely to make medication ordering errors. Throughout the course of the academic year, the odds of a medication ordering error decreased by 16% (aOR 0.84, 95% CI 0.80-0.89).

CONCLUSIONS

Despite electronic medical records, medication ordering errors by trainees remain common. Additional supervision and resident education regarding medication orders may be necessary.

The effect of prescriber education on medication-related patient harm in the hospital: a systematic review

AIMS

Educating prescribers is a strategy to reduce prescription errors in hospitals. The present systematic review gives an overview of original research papers on the education of prescribers and reporting outcomes on (potential) patient harm.

METHODS

A search of the databases Embase and Medline, using the Ovid interface, was performed. Research on the effect of physician education in order to prevent medication-related problems in inpatients, and on reporting original data and outcomes on prescribing errors and/or (potential) patient harm, was included. The assessment of methodological quality and risk of bias was performed using the Methodological Index for Non-Randomized studies (MINORS) checklist and the suggested risk of bias criteria for Effective Practice and Organization of Care (EPOC) reviews.

RESULTS

Eight studies investigated an intervention on education alone, and in seven studies education was the main part of a multifaceted intervention. All studies were small and had short follow-up periods. The educational programmes varied and were given to physicians of different specialties and levels of experience. Most studies reported intermediate process parameters as the outcome. The risk of performance and reporting bias were high.

CONCLUSION

All included studies suffered from poor methodology. The majority, especially studies in which education was part of a multifaceted intervention, reported effectiveness on intermediate outcome markers as prescription errors and potential adverse drug events. However, we found no firm evidence that educating prescribers in the hospital leads to a decrease in patient harm. Further work is needed to develop educational programmes, accompanied by more high-quality research with outcomes on the improvement of patient care.

Impact of patient-based teaching in improving prescription writing skills of II MBBS students

Background:

Although prescription writing is a part of the medical students' curriculum, their prescribing skills are still poor either as a part of their examinations or as they go out as qualified health professionals which may be due to inadequate training. Educational intervention like patient-based teaching in pharmacology offers lifelike preparation and provides more relevance, easier recall, and help in improving prescribing skills. This study aims to determine the role of patient-based teaching in improving the prescribing skill of II year medical students compared to conventional case-based teaching.

Materials and Methods:

This prospective, comparative study was carried out after giving orientation to prescription writing as per the WHO prescribing guidelines (N = 50). The 25 students in control group were given case-based teaching and 25 students in test group were given patient-based teaching of prescription writing for the same five common clinical conditions. The prescription writing skill (knows how level) was assessed by evaluating the prescriptions written in the prescribed format and scored by a 14-point scoring system.

Results:

The mean scores obtained by the control (9.6) and test (12.04) groups were compared by unpaired Student’s t-test (P < 0.001). On comparing the individual parameters in the 14-point scoring by Chi-square test, significant difference was found regarding patient and doctor’s particulars, diagnosis, quantity, duration of therapy, and signature between study groups. Student feedback revealed that patient-based teaching enhanced responsibility, focus, and memory.

Conclusion:

Patient-based approach for prescription writing enables students to develop prescribing skills in a complete and professional way.

Impact of a Drug Shortage on Medication Errors and Clinical Outcomes in the Pediatric Intensive Care Unit

OBJECTIVES

The purpose of this study was to assess the rate of prescribing errors, resulting adverse events, and patient outcomes associated with sedation and analgesia in the pediatric intensive care unit (PICU) before and during a national shortage of fentanyl and injectable benzodiazepines.

METHODS

A retrospective chart review was performed of patients admitted to the PICU with at least 1 prescribed order for a sedative or analgesic agent during the time periods of January to February of 2011 and 2012. Initial orders for sedative and analgesic agents were identified and investigated for appropriateness of dose and were assessed for error-associated adverse events. Orders were stratified by timing in regard to clinical pharmacist on-site availability. Demographic and outcome information, including unintended extubations, ventilator days, and PICU length of stay, were gathered.

RESULTS

One hundred sixty-nine orders representing 72 patients and 179 orders representing 75 patients in 2011 and 2012, respectively, were included in analysis. No differences were found in the rate of prescribing errors in 2011 and 2012 (33 errors in 169 orders vs. 39 errors in 179 orders, respectively, p=0.603). No differences were found in rates of prescribing errors in regard to clinical pharmacist on-site availability. A significant increase was seen in unintended extubations per 100 ventilator days, with 0.15 in 2011 vs. 1.13 in 2012, respectively (p<0.001). A significant decrease was seen in ventilator days per patient (p<0.001) and PICU length of stay per patient (p=0.019).

CONCLUSIONS

There were no differences in rates of prescribing errors before versus during the fentanyl and benzodiazepine shortage.

Confidence in Prescription Writing among Junior Physicians in Trinidad and Tobago

BACKGROUND

A fundamental skill in the practice of medicine is the ability to safely and rationally prescribe drugs. This research aims to estimate the percentage of newly registered medical officers who reported confidence in writing prescriptions.

METHODS

A questionnaire was distributed to 200 medical officers employed at public health tertiary institutions throughout Trinidad and Tobago. These comprised medical interns (provisionally registered) and house officers (fully registered). Participants indicated their confidence or reluctance to prescribe with or without supervision. Estimates and comparisons between the two groups were obtained using Fisher's exact and Chi-squared tests.

RESULTS

The response rate was 73.5%. More medical interns (68%; n = 41) than house officers (56%; n = 42) stated that they were 'Confident' or 'Very Confident' (p = 0.126) to prescribe. Approximately eighty-four per cent (83.6%; n = 51) of medical interns and 89.2% (n = 66) of house officers felt confident to prescribe antibiotics (p = 0.465). A greater percentage of medical interns (84.2%; n = 50) than house officers (66.7%; n = 49) agreed that undergraduate training equipped them to write prescriptions safely and rationally (c² = 6.17, df = 1; p = 0.012).

CONCLUSIONS

While most recent medical graduates felt confident about their prescription writing, there is a need to objectively measure this ability.

Which non-technical skills do junior doctors require to prescribe safely? A systematic review

AIMS

Prescribing errors are a major source of avoidable morbidity and mortality. Junior doctors write most in-hospital prescriptions and are the least experienced members of the healthcare team. This puts them at high risk of error and makes them attractive targets for interventions to improve prescription safety. Error analysis has shown a background of complex environments with multiple contributory conditions. Similar conditions in other high risk industries, such as aviation, have led to an increased understanding of so-called human factors and the use of non-technical skills (NTS) training to try to reduce error. To date no research has examined the NTS required for safe prescribing. The aim of this review was to develop a prototype NTS taxonomy for safe prescribing, by junior doctors, in hospital settings.

METHODS

A systematic search identified 14 studies analyzing prescribing behaviours and errors by junior doctors. Framework analysis was used to extract data from the studies and identify behaviours related to categories of NTS that might be relevant to safe and effective prescribing performance by junior doctors. Categories were derived from existing literature and inductively from the data.

RESULTS

A prototype taxonomy of relevant categories (situational awareness, decision making, communication and team working, and task management) and elements was constructed.

CONCLUSIONS

This prototype will form the basis of future work to create a tool that can be used for training and assessment of medical students and junior doctors to reduce prescribing error in the future.

Development and validation of an instrument to assess the prescribing readiness of medical students in Malaysia

BACKGROUND

Prescribing incompetence is an important factor that contributes to prescribing error, and this is often due to inadequate training during medical schools. We therefore aimed to develop and validate an instrument to assess the prescribing readiness of medical students (PROMS) in Malaysia.

METHODS

The PROMS comprised of 26 items with four domains: undergraduate learning opportunities; hands-on clinical skills practice; information gathering behaviour; and factors affecting the learning of prescribing skills. The first three domains were adapted from an existing questionnaire, while items from the last domain were formulated based on findings from a nominal group discussion. Face and content validity was determined by an expert panel, pilot tested in a class of final year (Year 5) medical students, and assessed using the Flesch reading ease. To assess the reliability of the PROMS, the internal consistency and test-retest (at baseline and 2 weeks later) were assessed using the Wilcoxon Signed Ranks test and Spearman's rho. The discriminative validity of the PROMS was assessed using the Mann-Whitney U-test (to assess if the PROMS could discriminate between final year medical students from a public and a private university).

RESULTS

A total of 119 medical students were recruited. Flesch reading ease was 46.9, indicating that the instrument was suitable for use in participants undergoing tertiary education. The overall Cronbach alpha value of the PROMS was 0.695, which was satisfactory. Test-retest showed no difference for 25/26 items, indicating that our instrument was reliable. Responses from the public and private university final year medical students were significantly different in 10/26 items, indicating that the PROMS was able to discriminate between these two groups. Medical students from the private university reported fewer learning opportunities and hands-on practice compared to those from the public university. On the other hand, medical students from the private university reported more frequent use of both web based and non-web-based resources compared to their public university counterparts.

CONCLUSIONS

The PROMS instrument was found to be a reliable and valid tool for assessing medical students' readiness to prescribe in Malaysia. It may also inform on the adequacy of medical programmes in training prescribing skills.

Educating medical trainees on medication reconciliation: a systematic review

BACKGROUND

Effective medication reconciliation is critical in reducing the risk of preventable adverse drug events. Medical trainees are often responsible for medication reconciliation on admission, transfer and discharge of the most vulnerable patients; therefore, it is important that trainees are educated on this aspect of quality care.

METHODS

We conducted a systematic review using MEDLINE and EMBASE databases to identify education initiatives targeted at improving trainee skill and knowledge in carrying out medication reconciliation. Studies published in English or French between July 1980 and July 2013, where the primary focus of the article was the role of medical trainees in conducting medication reconciliation, and where trainee-specific data was reported, were included. Included articles must have reported trainee-specific data. Given the anticipated heterogeneity and array of outcomes, we were unable to employ a specific tool in assessing the risk of bias across studies.

RESULTS

Seven studies met pre-specified eligibility criteria, indicating the lack of published education initiatives targeted towards improving trainee knowledge and experience. Four described an education intervention targeted towards students completing internal medicine clerkship, while the remaining 3 were implemented among residents. Although no two interventions were the same, 5 out of 7 included an experiential component.

CONCLUSIONS

Varying success was achieved with medication reconciliation education interventions. While some noted improved competence and/or confidence amongst trainees, namely undergraduate medical students, others noted little effect resulting from the intervention.

A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing

BACKGROUND

Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation.

METHOD

A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium-phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?

Educational interventions to improve prescribing competency: a systematic review

OBJECTIVE

To review the literature on educational interventions to improve prescribing and identify educational methods that improve prescribing competency in both medical and non-medical prescribers.

DESIGN

A systematic review was conducted. The databases Medline, International Pharmaceutical Abstracts (IPA), EMBASE and CINAHL were searched for articles in English published between January 1990 and July 2013.

SETTING

Primary and secondary care.

PARTICIPANTS

Medical and non-medical prescribers.

INTERVENTION

Education-based interventions to aid improvement in prescribing competency.

PRIMARY OUTCOME

Improvements in prescribing competency (knows how) or performance (shows how) as defined by Miller's competency model. This was primarily demonstrated through prescribing examinations, changes in prescribing habits or adherence to guidelines.

RESULTS

A total of 47 studies met the inclusion criteria and were included in the systematic review. Studies were categorised by their method of assessment, with 20 studies assessing prescribing competence and 27 assessing prescribing performance. A wide variety of educational interventions were employed, with different outcome measures and methods of assessments. In particular, six studies demonstrated that specific prescribing training using the WHO Guide to Good Prescribing increased prescribing competency in a wide variety of settings. Continuing medical education in the form of academic detailing and personalised prescriber feedback also yielded positive results. Only four studies evaluated educational interventions targeted at non-medical prescribers, highlighting that further research is needed in this area.

CONCLUSIONS

A broad range of educational interventions have been conducted to improve prescribing competency. The WHO Guide to Good Prescribing has the largest body of evidence to support its use and is a promising model for the design of targeted prescribing courses. There is a need for further development and evaluation of educational methods for non-medical prescribers.

A medical resident post-discharge phone call study

BACKGROUND

Several studies have identified the post-discharge period as a time of vulnerability for patients, and an opportunity exists to improve patient care. Adverse drug events are the most common events leading to complications during the post-discharge period. Recent studies have shown that using a scripted medication reconciliation process improves the quality of patient care.

OBJECTIVE

Does a phone call from a medical resident within 72 hours after hospital discharge improve patient satisfaction and quality of care? Does this exercise result in improved attitudes and competence for practice-based learning, and improvement and system-based practice of participating residents?

MATERIALS AND METHODS

This was a prospective randomized study comparing 1 group of patients that received a medication reconciliation phone call from a medical resident within 72 hours after discharge with a control group that did not receive a call. Adult patients aged ≥ 18 years on a medical resident service for ≥ 2 days and being discharged to home were invited to participate. The primary endpoint of the study was patient satisfaction. Secondary endpoints included readmission rates, emergency department visits, follow-up with the primary care provider, and resident attitudes and competence.

RESULTS

The primary and secondary endpoints did not reach statistical significance. However, a medication reconciliation error occurred in 48% of patients, and 93% of residents agreed that the phone call was beneficial to patient care.

CONCLUSION

Although patient satisfaction was not improved from this exercise, a follow-up call to patients after hospital discharge can identify otherwise missed medication reconciliation errors. Medical residents found the phone call to be worthwhile and gained valuable insight into their own discharge practices as demonstrated by self-reflection and intended change in discharge practices.

A new method for the assessment of patient safety competencies during a medical school clerkship using an objective structured clinical examination

INTRODUCTION

Patient safety is seldom assessed using objective evaluations during undergraduate medical education.

OBJECTIVE

To evaluate the performance of fifth-year medical students using an objective structured clinical examination focused on patient safety after implementation of an interactive program based on adverse events recognition and disclosure.

METHODS

In 2007, a patient safety program was implemented in the internal medicine clerkship of our hospital. The program focused on human error theory, epidemiology of incidents, adverse events, and disclosure. Upon completion of the program, students completed an objective structured clinical examination with five stations and standardized patients. One station focused on patient safety issues, including medical error recognition/disclosure, the patient-physician relationship and humanism issues. A standardized checklist was completed by each standardized patient to assess the performance of each student. The student's global performance at each station and performance in the domains of medical error, the patient-physician relationship and humanism were determined. The correlations between the student performances in these three domains were calculated.

RESULTS

A total of 95 students participated in the objective structured clinical examination. The mean global score at the patient safety station was 87.59 ± 1.24 points. Students' performance in the medical error domain was significantly lower than their performance on patient-physician relationship and humanistic issues. Less than 60% of students (n = 54) offered the simulated patient an apology after a medical error occurred. A significant correlation was found between scores obtained in the medical error domains and scores related to both the patient-physician relationship and humanistic domains.

CONCLUSIONS

An objective structured clinical examination is a useful tool to evaluate patient safety competencies during the medical student clerkship.

The performance of junior doctors in applying clinical pharmacology knowledge and prescribing skills to standardized clinical cases

AIMS

Recent studies suggest a worryingly high proportion of final year medical students and new doctors feel unprepared for effective and safe prescribing. Little research has been undertaken on UK junior doctors to see if these perceptions translate into unsafe prescribing practice. We aimed to measure the performance of foundation year 1 (FY1) doctors in applying clinical pharmacology and therapeutics (CPT) knowledge and prescribing skills using standardized clinical cases.

METHODS

A subject matter expert (SME) panel constructed a blueprint, and from these, twelve assessments focusing on areas posing high risk to patient safety and deemed as essential for FY1 doctors to know were chosen. Assessments comprised six extended matching questions (EMQs) and six written unobserved structured clinical examinations (WUSCEs) covering seven CPT domains. Two of each assessment types were administered over three time points to 128 FY1 doctors.

RESULTS

The twelve assessments were valid and statistically reliable. Across seven CPT areas tested 51-75% of FY1 doctors failed EMQs and 27-70% failed WUSCEs. The WUSCEs showed three performance trends; 30% of FY1 doctors consistently performing poorly, 50% performing around the passing score, and 20% performing consistently well. Categorical rating of the WUSCEs revealed 5% (8/161) of scripts contained errors deemed as potentially lethal.

CONCLUSIONS

This study showed that a large proportion of FY1 doctors failed to demonstrate the level of CPT knowledge and prescribing ability required at this stage of their careers. We identified areas of performance weakness that posed high risk to patient safety and suggested ways to improve the prescribing by FY1 doctors.

Medical clerkships do not reduce common prescription errors among medical students

Prescribing correctly represents one of the most essential skills of a doctor when it comes to patient safety. Unfortunately, prescribing errors still account for a large proportion of avoidable drug-related problems (DRP). Despite this shortcoming, many medical schools do not provide specific prescribing training and assume that students acquire sufficient prescribing skills during regular medical clerkships. We therefore investigated whether there is an association between the individual time spent by students in internal-medicine clerkships and the number of prescription errors committed in a standardized prescribing test for common drug-related problems in a medical inpatient setting. Seventy-four fifth-year medical students (25 +/- 3 yrs, 24 m, 50 f) who had completed their formal pharmacology training filled in prescription charts for two standardized patient paper cases. The charts were rated by two blinded consultants from the field of internal medicine using a checklist for common prescription errors. Students were divided into three groups according to the number of weeks previously spent in internal-medicine clerkships. Group differences in the number of prescription errors made were subsequently examined. Students committed 69% +/- 12% of all possible prescription mistakes. There was no significant difference between the group without clerkships in internal medicine (G1) (71 +/- 9%), the group with one to four weeks (G2) (67 +/- 15%), and the group with more than five weeks of clerkships (G3) (71 +/- 10%), p = .76. Medical students do not seem to acquire the necessary skills to avoid common prescription errors during regular clerkships in internal medicine. This study provides evidence to suggest that specific prescription training within medical education is warranted in order to prevent DRP.

The causes of and factors associated with prescribing errors in hospital inpatients: a systematic review

Prescribing errors are common, they result in adverse events and harm to patients and it is unclear how best to prevent them because recommendations are more often based on surmized rather than empirically collected data. The aim of this systematic review was to identify all informative published evidence concerning the causes of and factors associated with prescribing errors in specialist and non-specialist hospitals, collate it, analyse it qualitatively and synthesize conclusions from it. Seven electronic databases were searched for articles published between 1985-July 2008. The reference lists of all informative studies were searched for additional citations. To be included, a study had to be of handwritten prescriptions for adult or child inpatients that reported empirically collected data on the causes of or factors associated with errors. Publications in languages other than English and studies that evaluated errors for only one disease, one route of administration or one type of prescribing error were excluded. Seventeen papers reporting 16 studies, selected from 1268 papers identified by the search, were included in the review. Studies from the US and the UK in university-affiliated hospitals predominated (10/16 [62%]). The definition of a prescribing error varied widely and the included studies were highly heterogeneous. Causes were grouped according to Reason's model of accident causation into active failures, error-provoking conditions and latent conditions. The active failure most frequently cited was a mistake due to inadequate knowledge of the drug or the patient. Skills-based slips and memory lapses were also common. Where error-provoking conditions were reported, there was at least one per error. These included lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between healthcare professionals. Latent conditions included reluctance to question senior colleagues and inadequate provision of training. Prescribing errors are often multifactorial, with several active failures and error-provoking conditions often acting together to cause them. In the face of such complexity, solutions addressing a single cause, such as lack of knowledge, are likely to have only limited benefit. Further rigorous study, seeking potential ways of reducing error, needs to be conducted. Multifactorial interventions across many parts of the system are likely to be required.

Problem-based training for medical students reduces common prescription errors: a randomised controlled trial

CONTEXT

Avoidable drug-related problems (DRPs) cause substantial morbidity, mortality and costs. As most prescription errors are committed by recently graduated doctors, undergraduate training should specifically address DRPs.

OBJECTIVES

This study set out to investigate whether a DRP teaching module can reduce prescription errors made by advanced medical students in varying clinical contexts.

METHODS

A total of 74 Year 5 medical students (mean age 25 +/- 3 years; 24 men, 50 women) participated in a randomised controlled crossover study. Students filled in patients' prescription charts before and after a special DRP training module and a control intervention. The 1-week training module comprised a seminar on common prescription errors, a prescribing exercise with a standardised paper case patient, drafting of inoperative prescription charts for real patients and discussions with a lecturer. During the observation points, prescription charts for standardised patient cases in different clinical contexts had to be completed. These prescription charts were subsequently analysed by two independent raters using a checklist for common prescription errors.

RESULTS

Prior to training, students committed a mean of 69 +/- 12% of the potential prescription errors. This decreased to 29 +/- 15% after DRP training (P < 0.001).

CONCLUSIONS

Prescription errors can be significantly reduced in a relatively brief training time by implementing a specific DRP teaching module.

Teaching of medical pharmacology: the need to nurture the early development of desired attitudes for safe and rational drug prescribing

Pharmacology, as a basic medical science discipline, provides the scientific basis of therapeutics, i.e. the scientific foundation for safe and rational prescribing of drugs. The public, lay media, and the medical profession have raised serious concerns over the high incidence of errors of drug prescribing which compromise patient safety, including death of some patients, attributed mainly to inadequate teaching of medical pharmacology and, consequently, to medical graduates lacking skills in safe and effective drug prescribing. There is also overwhelming evidence that the pervasive and prevalent doctor-drug industry relationships have a strong influence over the prescribing habits and drug education of doctors. The British Pharmacological Society and American Association of Medical Colleges have crafted some insightful guidelines, including the learning of desired attitudes, for designing a medical pharmacology curriculum aimed at enhancing patient safety. This article will critically review the major issues relating to errors of drug prescribing, including the need to nurture the early development of desired attitudes which foster safe and rational drug prescribing. A simple educational approach, using a task analysis of drug prescribing, is applied to identify desired attitudes which should be incorporated into a basic pharmacology course for medical students in the twenty-first century.

A survey of drug-dose calculation skills of Australian tertiary hospital doctors

OBJECTIVE

To assess the ability of doctors to calculate drug doses and their workplace prescribing and calculation habits.

DESIGN AND SETTING

Prospective, questionnaire-based observational study conducted at a 570-bed teaching hospital in February 2007.

PARTICIPANTS

Convenience sample of 190 doctors, representing all acute medical and surgical disciplines and diverse levels of experience.

MAIN OUTCOME MEASURES

Demographic data, self-reported prescribing habits, predicted score on a 12-item test of ability to calculate drug doses, score considered adequate for peers, and actual score.

RESULTS

141 doctors (74%) completed the questionnaire. The mean actual score on the test was 72.5% (95% CI, 67.8%-77.3%), which was similar to the group's mean predicted score (74.7%; 95% CI, 71.0%-78.5%) but significantly lower than the mean of the score they considered adequate (91.6%; 95% CI, 89.5%-93.8%) (P < 0.001). Subgroup analyses showed that senior doctors and those in critical care specialties (intensive care, emergency medicine and anaesthesia) achieved significantly higher actual scores than junior doctors and those in non-critical care specialties, respectively.

CONCLUSIONS

Doctors expect their colleagues to perform significantly better in a drug-dose calculation test than they expect to, or can achieve, themselves. Junior staff and those in non-critical care specialties should be targeted for education in the skill of drug-dose calculation to reduce the risk of medication error and its consequences.

A context-learning pharmacotherapy program for preclinical medical students leads to more rational drug prescribing during their clinical clerkship in internal medicine

The irrational prescribing of drugs seems to be a general problem in medical practice, occasionally leading to serious consequences. In order to improve the drug prescribing performance of medical students, a compulsory context-learning pharmacotherapy module was implemented in 1998 in the medical curriculum of 2nd-4th-year medical students at theVU University Medical Center (VUmc), Amsterdam, The Netherlands. As part of this program, preclinical medical students are taught how to select, prescribe, and evaluate a drug regimen rationally. The aim of this study was to investigate the effect of this preclinical pharmacotherapy program on the quality of rational prescribing during the ensuing clinical clerkship of these students in internal medicine. The results of this study indicate that preclinical context-learning in pharmacotherapy leads to the use of more rational prescribing modalities by medical students during their ensuing clinical clerkship in internal medicine. This effect was obtained not only with respect to the clinical topics in which training had been given as part of the pharmacotherapy curriculum, but also for other disease situations that the students dealt with. This implies that students not only remember the specific information they have learned during the training, but are also able to apply the acquired skills in new situations (transfer effect).

Reducing medication prescribing errors in a teaching hospital

BACKGROUND

Medication errors occur frequently, result in significant morbidity and mortality, and are often preventable. A multifaceted intervention was conducted to reduce prescribing errors in handwritten medication orders written by house staff.

METHODS

A before-and-after design was used to evaluate the intervention--which included grand rounds, an interactive presentation for house staff, and reminders (a checklist, chart inserts, and requests for clarification)--and targeted 20 safe prescribing behaviors.

RESULTS

At baseline, prescribing errors were more common among surgical house staff than medical house staff (1.08 errors/order versus 0.76 errors/order, p < .001). Only 1% of orders contained an overt error, but 49% were incomplete, 27% contained dangerous dose and frequency abbreviations, and 17% were illegible. Postintervention, the mean number of prescribing errors per order decreased for surgical house staff from 1.08 (standard deviation [SD], 0.23) to 0.85 (SD, 0.11; p < .001), with a more marked effect for house staff who attended the didactic portion of the intervention. In addition, the mean number of the more significant errors per order decreased from 0.65 (SD, 0.19) to 0.45 (SD, 0.13; p < .001), and significant decreases occurred in the proportion of orders that were incomplete, were illegible, and contained an overt error. However, prescribing errors per order increased in orders written by medical house staff from 0.76 (SD, 0.14) to 0.98 (SD, 0.11; p < .001).

DISCUSSION

The intervention was associated with a modest improvement in the quality of medication orders written by surgical house staff. To reduce prescribing errors, multilevel interventions are needed, including training in safe prescribing for all physicians. Such training may need to be started in medical school and augmented and reinforced throughout residency.

Teaching medication reconciliation through simulation: a patient safety initiative for second year medical students

INTRODUCTION

Errors in medication reconciliation constitute a large area of potential injury to patients. Medication reconciliation is rarely incorporated into medical school curriculums so students learn primarily from observing clinical care.

AIM

To design and implement an interactive learning exercise to teach second year medical students about medication reconciliation

SETTING

Northwestern University Feinberg School of Medicine, Chicago, IL PROGRAM DESCRIPTION: The Medication Reconciliation Simulation teaches medical students how to elicit information from active real-world sources to reconcile a medication history.

PROGRAM EVALUATION

At the conclusion of the session, students completed a Likert scale survey rating the level of improvement in their knowledge and comfort in obtaining medication histories. Students rated their knowledge level as having increased by 27% and their comfort level as having increased by 20%. A full 91% of the 158 students felt that it should be performed again for the following medical student class.

DISCUSSION

The Medication Reconciliation Simulation is the first to specifically target medication reconciliation as a curriculum topic for medical students. Students praised the entertaining simulation and felt it provided a very meaningful experience on the patient safety topic. This simulation is generalizable to other institutions interested in teaching medication reconciliation and improving medication safety.

Learning from error: identifying contributory causes of medication errors in an Australian hospital

OBJECTIVE

To study the clinical contexts contributing to harmful medication errors.

DESIGN, SETTING AND PARTICIPANTS

A qualitative study using semi-structured interviews was conducted between March and August 2005 at Fremantle Hospital, a 450-bed metropolitan teaching hospital. Twenty-six of 46 staff members (57%) identified by pharmacy staff as having contributed to a significant medication error were interviewed. Interviews were recorded and transcribed for thematic analysis.

RESULTS

Most errors were due to slips in attention that occurred during routine prescribing, dispensing or drug administration. Knowledge-based mistakes (eg, failure to follow a protocol) also contributed to prescribing errors. Errors were more likely to occur during tasks being carried out after hours by busy, distracted staff, often in relation to unfamiliar patients. Communication problems with senior staff and difficulty accessing appropriate drug dosing information contributed to knowledge-based prescribing errors. Several medical staff were unaware they had committed an error until their involvement with our study.

CONCLUSIONS

Contextual factors that contributed to slips, lapses and knowledge-based mistakes in our sample are likely to be widespread in hospitals, and their impact on medication error may be substantial. Staff need training in how to recognise and deal with error-prone clinical situations. Safe prescribing practices (eg, the absolute requirement to acquire information before prescribing unfamiliar drugs) must be emphasised. Improved access to drug information at the point of prescribing, attention to communication barriers, and increasing staffing levels in particular areas are other potential strategies for reducing error.

Safe medication practice: attitudes of medical students about to begin their intern year

OBJECTIVES

Interns are expected to prescribe effectively and safely. This study aimed to assess medical students' perceptions of their readiness to prescribe, associated risks and outcome if involved in an error, as well as their perceptions of available support.

METHODS

We carried out a survey of 101 students prior to their intern year using a structured questionnaire. An indication of agreement with 21 closed statements was sought. Thematic clusters were identified by factor analysis.

RESULTS

Most students (84) felt they would be able to prescribe for most simple complaints and complete discharge prescriptions (81). In high-risk situations, fewer students felt comfortable with prescribing: only 54 felt sufficiently confident to prescribe warfarin and 66 felt confident enough to order i.v. fluids. Many felt support such as guidelines was available (87) and that, if in doubt, they could clarify instructions and seek advice. Students were aware of errors occurring within the medication system; however, most (99) believed that the medicines they prescribed would be safely administered. There was a mixed perception of medication errors: 40 felt that their prescribing errors would not be dealt with constructively and 79 indicated that a culture existed at their hospitals where clinicians would be blamed if they made a prescribing error.

CONCLUSIONS

At the end of medical school education and prior to assuming responsibility for prescribing, students felt unprepared and perceived that negative outcomes would result if they were involved in errors. These findings indicate that much more work is needed to prepare doctors to prescribe safely, improve the safety of prescribing systems and address the issue of blame.

Development and evaluation of a 1-day interclerkship program for medical students on medical errors and patient safety

Medical students need to be well informed about medical errors and patient safety. Pursuant to a needs assessment and pilot program, 229 third-year students participated in a 1-day program on patient safety including a plenary session and workshops. Attitudes and beliefs were measured by a survey at the beginning and end of the program. Completed surveys were returned by 124 (54%) students. Their level of agreement with 14 of 21 rating scale items changed in the expected direction. There were 7 items in which the students' baseline responses were already positive and did not change significantly. A 1-day program on patient safety in the third year of medical school can change students' attitudes and beliefs. There may be a subset of students needing closer attention. The findings provide evidence for the validity of the attitude survey and reinforce the effectiveness of interclerkship programs in medical schools.

Safe prescribing: an educational intervention for medical students

BACKGROUND AND PURPOSE

Errors in handwritten medication orders are common and can result in patient harm. We evaluated an intervention for increasing safe prescribing by medical students.

METHODS

We conducted a pre-post evaluation to evaluate a brief educational intervention to increase safe prescribing by medical students. Two 1-hr, small-group, interactive educational sessions for 3rd-year medical students were held 2 weeks apart at Washington University in St. Louis. Prescribing errors were measured with a verbal transcription test.

RESULTS

Twenty-eight students participated. Following the intervention, the average number of error-free orders in the 10-order test increased 5-fold from 0.82 per student to 4.54 per student, and the average number of errors and dangerous errors per student decreased from 13.96 to 7.36 (p < .0001) and from 4.75 to 2.68 (p < .0001), respectively.

CONCLUSIONS

After a brief interactive educational intervention for medical students, the frequency of error-free handwritten orders increased, and prescribing errors decreased. Additional training may be required to further improve and maintain safe prescribing.