Improving junior doctor medicine prescribing and patient safety: An intervention using personalised, structured, video-enhanced feedback and deliberate practice

Reducing trainee mistakes. Better performance with changing to a high-fidelity simulation system?

BACKGROUND

Postpartum hemorrhage is a significant cause of both maternal morbidity and mortality worldwide and is increasing in incidence. This study aimed to assess improvement and identify shortcomings in trainee performance in different simulation systems in the management of postpartum hemorrhage.

OBJECTIVE

To perform a pilot study evaluating and comparing high- and low-fidelity simulation models, assessing improvement in repeated performance with high-fidelity mode and identifying mistakes made assessed using Objective Structured Assessment of Technical Skills and thereby exploring what aspects of emergency management of postpartum hemorrhage should be prioritized in teaching settings and assessing what simulation setup is most effective in achieving competence.

STUDY DESIGN

This was a prospective randomized, single-blinded, single-institution trial in a population of 17 junior obstetrical trainees at the Charité University Hospital Obstetric Simulation Center in Berlin. Trainees were randomized into 2 groups, with either initial low-fidelity simulation or high-fidelity simulation, followed by repeated assessment of performance, using the high-fidelity model simulation system. Individual simulation sessions were video-recorded and transcribed, and the timing of interventions was documented. Strandardized Objective Structured Assessment of Technical Skills forms were used as a checklist for performance.

RESULTS

There was a statistically significant general improvement in performance (P=.02; 24.7-27.2 of 31.0 points; average of 8.7%) in the second cycle of simulation assessment and a statistically significant training effect (P=.043; 24.4-28.4 of 31.0 points; average of 12.9%) in the group that underwent repeat simulation assessment from the initial low-fidelity system to the high-fidelity system compared with the group using the same high-fidelity setup (P=.276; 25.0-25.8 of 31.0; average of 2.4%).

CONCLUSION

There was an improvement in the performance when trainees underwent a repeated cycle of simulation assessment changing from a low-fidelity system to a high-fidelity system. Simulation assessment can identify mistakes and learning gaps that are important for obstetrical trainees. This study found that trainees make the same mistakes, regardless of which simulation model was initially used.

Assessment of prescription writing skills among dental house officers: A multi-center study

Objective

To assess the knowledge and skills of prescription writing among dental house officers from different hospitals.

Methods

This cross-sectional study was conducted from July to September, 2022. A self-administered, structured questionnaire was used to collect data from 180 house officers from four teaching dental hospitals (n=45 each). The participants were asked to write a prescription for an adult and a pediatric patient. The prescription was evaluated according to WHO criteria. Analysis was done using SPSS v.20. Data was presented as frequencies and percentages.

Results

Among the 180 participants, 42.9% were males and 57.1% were females. 33.9% participants reported prescription writing to be a difficult task. Only 36.7% participants reported to be trained in prescribing pediatric medications. None of the prescriptions completely fulfilled the WHO criteria. Doctor related information (name, address and contact no) was written by only 3.8% of the participants while 10% of the participants mentioned the patient related information (name, address and age). Dosage of the prescribed drugs was the most commonly drug-related missing parameter which was mentioned in 30% of the pediatric prescriptions and 21% of the adult prescriptions.

Conclusion

There is a general lack of knowledge among the dental house officers regarding prescription writing as they were found to be unaware of the essential elements of a prescription. The findings call for an urgent change in the undergraduate teaching of prescription writing skills with special emphasis on pediatric drugs and dosage.

Evaluating the UK's first national prescribing assessment for GPs in training using an online survey

BACKGROUND

GP trainees may not have experienced a systematic and comprehensive education in safe prescribing. Therefore, a self-assessment prescribing review was developed.

AIM

To determine whether the assessment was feasible, had face validity, and did not disadvantage particular groups of participants.

DESIGN & SETTING

An online survey that evaluates the opinions of GPs in training of a prescribing assessment in the UK. All full-time UK trainees who started their final year of GP training in August 2019 undertook the prescribing assessment along with their trainers, after which they completed an online anonymous feedback questionnaire.

METHOD

The questionnaire completed by trainees sought their opinions of the assessment, and collected ethnicity and disability data. The trainer questionnaire was similar but did not include any demographic information.

RESULTS

The questionnaire was completed by 1741 trainees and 1576 trainers. There was no evidence that ethnic group and disability were related to aspects of the review. Most of the trainees (76.4%, n = 1330) and trainers (82.0%, n = 1293) agreed or strongly agreed that the prescribing review was helpful for assessing and learning about the trainee's prescribing. However, most participants (63.2%, n = 1092) took >4 hours to review their prescriptions. A majority of trainees (90.2%, n = 1571) reported that completing the assessment had resulted in a change in their prescribing practice.

CONCLUSION

The majority of trainers and trainees reported that the prescribing assessment was helpful. The study was not able to assess whether there had been an actual change in practice that resulted in an error reduction.

Can a novel constructivist theory-informed feedback intervention reduce prescribing errors ? A pre-post study

CONTEXT

Medical interns (interns) find prescribing challenging and many report lacking readiness when commencing work. Errors in prescribing puts patients' safety at risk. Yet error rates remain high, despite education, supervision and pharmacists' contributions. Feedback on prescribing may improve performance. Yet, work-based prescribing feedback practices focus on rectifying errors. We aimed to explore if prescribing can be improved using a theory-informed feedback intervention.

METHODS

In this pre-post study, we designed and implemented a constructivist-theory informed prescribing feedback intervention, informed by Feedback-Mark 2 Theory. Interns commencing internal medicine terms in two Australian teaching hospitals were invited to engage in the feedback intervention. Their prescribing was evaluated by comparing errors per medication order of at least 30 orders per intern. Pre/baseline (weeks 1-3) were compared with post intervention (weeks 8-9). Interns' baseline prescribing audit findings were analysed and discussed at individualised feedback sessions. These sessions were with a clinical pharmacologist (Site 1) and a pharmacist educator (Site 2).

RESULTS

Eighty eight intern's prescribing over five 10-week terms was analysed from two hospitals. The frequency of prescribing errors significantly reduced at both sites after the intervention, across all five terms (p < 0.001).There were initially 1598 errors in 2750 orders (median [IQR] 0.48 [0.35-0.67] errors per order) and after the intervention 1113 errors in 2694 orders (median [IQR] 0.30 [0.17-0.50] errors per order).

CONCLUSION

Our findings suggest interns' prescribing practices may improve as a result of constructivist -theory learner centred, informed feedback with an agreed plan. This novel intervention, contributed, to a reduction in interns' prescribing errors. This study suggests new strategies for improving prescribing safety should include the design and implementation of theory-informed feedback interventions.

Learning from electronic prescribing errors: a mixed methods study of junior doctors' perceptions of training and individualised feedback data

OBJECTIVES

To explore the views of junior doctors towards (1) electronic prescribing (EP) training and feedback, (2) readiness for receiving individualised feedback data about EP errors and (3) preferences for receiving and learning from EP feedback.

DESIGN

Explanatory sequential mixed methods study comprising quantitative survey (phase 1), followed by interviews and focus group discussions (phase 2).

SETTING

Three acute hospitals of a large English National Health Service organisation.

PARTICIPANTS

25 of 89 foundation year 1 and 2 doctors completed the phase 1 survey; 5 participated in semi-structured interviews and 7 in a focus group in phase 2.

RESULTS

Foundation doctors in this mixed methods study reported that current feedback provision on EP errors was lacking or informal, and that existing EP training and resources were underused. They believed feedback about prescribing errors to be important and were keen to receive real-time, individualised EP feedback data. Feedback needed to be in manageable amounts, motivational and clearly signposting how to learn or improve. Participants wanted feedback and better training on the EP system to prevent repeating errors. In addition to individualised EP error data, they were positive about learning from general prescribing errors and aggregated EP data. However, there was a lack of consensus about how best to learn from statistical data. Potential limitations identified by participants included concern about how the data would be collected and whether it would be truly reflective of their performance.

CONCLUSIONS

Junior doctors would value feedback on their prescribing, and are keen to learn from EP errors, develop their clinical prescribing skills and use the EP interface effectively. We identified preferences for EP technology to enable provision of real-time data in combination with feedback to support learning and potentially reduce prescribing errors.

Professional qualifications of medical affairs pharmaceutical physicians and other internal stakeholders in the pharmaceutical industry

Background: Medical affairs pharmaceutical physicians (MAPPs) have unique value to pharmaceutical companies due to their accountability for activities that benefit regulators, payors, prescribers and patients. This study assessed whether MAPPs' specialist training and education in pharmaceutical medicine could account for this level of value by determining whether there was significant variation in education and training between MAPPs and other internal stakeholders of pharmaceutical companies. Methods: A systematic search of LinkedIn profiles from the 10 pharmaceutical companies by revenue was conducted between June and October 2021. Job title and type and year of undergraduate and postgraduate qualifications were extracted. A one-sided Mann-Whitney test assessed for differences in the total number of qualifications between MAPPs and other internal stakeholders involved in medical affairs using MAPPs as the reference group. Other internal stakeholders included medical affairs pharmacists (MAPharm), other medical affairs professionals (MAOth), and market access (MAcc), commercial (COmm) and sales professionals. Sub-group analysis determined differences in undergraduate and postgraduate education. Results: In total, 524 profiles were included. Compared to all other internal stakeholders, MAPPs had a significantly higher number of undergraduate (p < 0.001) and postgraduate (MAPharm, p = 0.003; MAOth, p = 0.004; MAcc, COmm and Sales, p < 0.001) qualifications. Additionally, MAPPs had a significantly longer time to industry than other internal stakeholders apart from MAPharm. Of those with clinical qualifications, MAPPs were almost twice as likely to have business qualifications. Conclusions: Of all internal stakeholders, MAPPs had the highest number of qualifications and the best match between expertise and the contextual demands of decision-makers in the pharmaceutical industry. Pharmaceutical companies in the UK can use these findings to clarify role boundaries and decision-making power based on the nature and level of expertise of each internal stakeholder.

Implementation and evaluation of a good prescribing tip email to reduce junior doctors' prescribing errors

Background

Prescribing errors are common, occurring in 7% of in-patient medication orders in UK hospitals. Foundation Year 1 (F1) doctors have reported a lack of feedback on prescribing as a cause of errors.

Aim

To evaluate the effect of implementing a shared learning intervention to Foundation Year 1 doctors on their prescribing errors.

Methods

A shared learning intervention, ‘good prescribing tip’ emails, were designed and sent fortnightly to F1s to share feedback about common/serious prescribing errors occurring in the hospital. Ward pharmacists identified prescribing errors in newly prescribed in-patient and discharge medication orders for 2 weeks pre- and post-intervention during Winter/Spring 2017. The prevalence of prescribing errors was compared pre- and post-intervention using statistical analysis.

Results

Overall, there was a statistically significant reduction ( p < 0.05) in the prescribing error rate between pre-intervention (441 errors in 6190 prescriptions, 7.1%) and post-intervention (245 errors in 4866 prescriptions, 5.0%). When data were analysed by ward type there was a statistically significant reduction in the prescribing error rate on medical wards (6.8% to 4.5%) and on surgical wards (8.4% to 6.2%).

Conclusions

It is possible to design and implement a shared learning intervention, the ‘good prescribing tip’ email. Findings suggest that this intervention contributed to a reduction in the prevalence of prescribing errors across all wards, thereby improving patient safety.

Pharmacist-led, prescription intervention system-assisted feedback to reduce prescribing errors: A retrospective study

WHAT IS KNOWN AND OBJECTIVE

Prescribing errors are prevalent in hospital settings, with provision of feedback recommended to support prescribing by doctors. To evaluate the impact of a pharmacist-led prescription intervention system on prescribing error rates and to measure intervention efficiency.

METHODS

All prescribers in Shandong Provincial Third Hospital received feedback from ward pharmacists using a pharmacist-led prescription intervention system. The prescribing error rate was calculated from Oct 2019 to December 2020. After the intervention was applied, the rates of PASS 1 (System pass), PASS 2 (Pharmacist pass) and PASS 3 (Pharmacist-doctor pass) events and the feedback time were calculated each month.

RESULTS AND DISCUSSION

Irrational use of drugs was reduced and the prescription rate increased significantly. The error rate reduced from 6.94% to 1.96%, representing an estimated 71.76% decrease overall (p < 0.05). The PASS 1 rate gradually increased from 88% to 96% (p < 0.05), the PASS 2 rate gradually decreased from 5.06% to 2.04% (p < 0.05), the PASS 3 rate gradually decreased from 6.94% to 1.96% (p < 0.05).

WHAT IS NEW AND CONCLUSION

The pharmacist-led prescription intervention system has the potential to reduce prescribing errors and improve prescribing outcomes and patient safety.

Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation

Reflective practice is essential for the ongoing maturation of clinicians and requires regular self-evaluation in association with ongoing mentoring and feedback. Currently, most resident physicians do not have access to educational experiences that fulfill these needs. We present a novel model for structured one-on-one longitudinal coaching using the principles of deliberate practice to improve diagnostic skills. This is an easily implementable educational model that can be replicated in residencies across the country to improve clinical reasoning. Skills learned through this program have the potential not only to bolster the academic approach to patients but to also directly improve the clinical assessment and care of patients under the trainee's care.

Improving junior doctor medicine prescribing and patient safety: An intervention using personalised, structured, video-enhanced feedback and deliberate practice

AIMS

This research investigated the effectiveness of an intervention for improving the prescribing and patient safety behaviour among Foundation Year doctors. The intervention consisted of simulated clinical encounters with subsequent personalised, structured, video-enhanced feedback and deliberate practice, undertaken at the start of four-month sub-specialty rotations.

METHODS

Three prospective, non-randomised control intervention studies were conducted, within two secondary care NHS Trusts in England. The primary outcome measure, error rate per prescriber, was calculated using daily prescribing data. Prescribers were grouped to enable a comparison between experimental and control conditions using regression analysis. A break-even analysis evaluated cost-effectiveness.

RESULTS

There was no significant difference in error rates of novice prescribers who received the intervention when compared with those of experienced prescribers. Novice prescribers not participating in the intervention had significantly higher error rates (P = .026, 95% confidence interval [CI] Wald 0.093 to 1.436; P = .026, 95% CI 0.031 to 0.397) and patients seen by them experienced significantly higher prescribing error rates (P = .007, 95% CI 0.025 to 0.157). Conversely, patients seen by the novice prescribers who received the intervention experienced a significantly lower rate of significant errors compared to patients seen by the experienced prescribers (P = .04, 95% CI -0.068 to -0.001). The break-even analysis demonstrates cost-effectiveness for the intervention.

CONCLUSION

Simulated clinical encounters using personalised, structured, video-enhanced feedback and deliberate practice improves the prescribing and patient safety behaviour of Foundation Year doctors. The intervention is cost-effective with potential to reduce avoidable harm.