Is it time for a nontechnical skills approach to prescribing?

Effects of training physicians in electronic prescribing in the outpatient setting on clinical, learning and behavioural outcomes: a cluster randomized trial

AIMS

Electronic prescribing systems may improve medication safety, but only when used appropriately. The effects of task analysis-based training on clinical, learning and behavioural outcomes were evaluated in the outpatient setting, compared with the usual educational approach.

METHODS

This was a multicentre, cluster randomized trial [EDUCATional intervention for IT-mediated MEDication management (MEDUCATE trial)], with physicians as the unit of analysis. It took place in the outpatient clinics of two academic hospitals. Participants comprised specialists and residents (specialty trainees, in the UK) and their patients. Training took the form of a small-group session and an e-learning. The primary outcome was the proportion of medication discrepancies per physician, measured as discrepancies between medications registered by physicians in the electronic prescribing system and those reported by patients. Clinical consequences were estimated by the proportion of patients per physician with at least one missed drug-drug interaction with the potential for causing adverse drug events. A questionnaire assessed physicians' knowledge and skills.

RESULTS

Among 124 participating physicians, primary outcome data for 115 (93%) were available. A total of 1094 patients were included. A mean of 48% of registered medications per physician were discrepant with the medications that their patients reported in both groups (P = 0.14). Due to registration omissions, a mean of 4% of patients per physician had one or more missed drug-drug interactions with the potential to cause a clinically relevant adverse drug event in the intervention group, and 7% in controls (P = 0.11). The percentages of correct answers on the knowledge and skills test were higher in the intervention group (57%) compared with controls (51%; P = 0.01).

CONCLUSION

The training equipped outpatient physicians with the knowledge and skills for appropriate use of electronic prescribing systems, but had no effect on medication discrepancies.

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

OBJECTIVES

A key element of the implementation and ongoing use of an electronic prescribing (ePrescribing) system is ensuring that users are, and remain, sufficiently trained to use the system. Studies have suggested that insufficient training is associated with suboptimal use. However, it is not clear from these studies how clinicians are trained to use ePrescribing systems or the effectiveness of different approaches. We sought to describe the various approaches used to train qualified prescribers on ePrescribing systems and to identify whether users were educated about the pitfalls and challenges of using these systems.

METHODS

We performed a literature review, using a systematic approach across three large databases: Cumulative Index Nursing and Allied Health Literature, Embase and Medline were searched for relevant English language articles. Articles that explored the training of qualified prescribers on ePrescribing systems in a hospital setting were included.

KEY FINDINGS

Our search of 'all training' approaches returned 1155 publications, of which seven were included. A separate search of 'online' training found three relevant publications. Training methods in the 'all training' category included clinical scenarios, demonstrations and assessments. Regarding 'online' training approaches; a team at the University of Victoria in Canada developed a portal containing simulated versions of electronic health records, where individuals could prescribe for fictitious patients. Educating prescribers about the challenges and pitfalls of electronic systems was rarely discussed.

CONCLUSIONS

A number of methods are used to train prescribers; however, the lack of papers retrieved suggests a need for additional studies to inform training methods.

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.

Task analysis of information technology-mediated medication management in outpatient care

Aims

Educating physicians in the procedural as well as cognitive skills of information technology (IT)-mediated medication management could be one of the missing links for the improvement of patient safety. We aimed to compose a framework of tasks that need to be addressed to optimize medication management in outpatient care.

Methods

Formal task analysis: decomposition of a complex task into a set of subtasks. First, we obtained a general description of the medication management process from exploratory interviews. Secondly, we interviewed experts in-depth to further define tasks and subtasks. Setting: Outpatient care in different fields of medicine in six teaching and academic medical centres in the Netherlands and the United States. Participants: 20 experts. Tasks were divided up into procedural, cognitive and macrocognitive tasks and categorized into the three components of dynamic decision making.

Results

The medication management process consists of three components: (i) reviewing the medication situation; (ii) composing a treatment plan; and (iii) accomplishing and communicating a treatment and surveillance plan. Subtasks include multiple cognitive tasks such as composing a list of current medications and evaluating the reliability of sources, and procedural tasks such as documenting current medication. The identified macrocognitive tasks were: planning, integration of IT in workflow, managing uncertainties and responsibilities, and problem detection.

Conclusions

All identified procedural, cognitive and macrocognitive skills should be included when designing education for IT-mediated medication management. The resulting framework supports the design of educational interventions to improve IT-mediated medication management in outpatient care.