Cross-sectional study of prescribing errors in patients admitted to nine hospitals across North West England

Prescription Audit in Outpatient Pharmacy of a Tertiary Care Referral Hospital in Haryana Using World Health Organization/International Network of Rational Use of Drugs (WHO/INRUD) Core Prescribing Indicators: A Step Towards Refining Drug Use and Patient Care

BACKGROUND

The evaluation of internationally comparable indicators of medicine use is important to devise strategies to promote the rational use of medicines (RUM).

METHODS

A cross-sectional study was conducted in a tertiary care hospital from January to June 2024. Prescriptions were collected from the outpatient pharmacy using systematic random sampling and analyzed for WHO/INRUD core prescribing indicators, index of rational drug prescribing (IRDP) and completeness (general, treatment and prescribers' details).

RESULTS

Out of 844 prescriptions collected, 607 were analyzed. A total of 1837 drugs were prescribed, with a mean (SD) of 3.03 (1.51) drugs per prescription; 1378 (75%) drugs were prescribed as generic names; 125 prescriptions (20.59%) had an antibiotic prescribed; and injectables were given in 7 (1.15%) prescriptions. Of the total 1837 drugs, 1018 (55.4%) were mentioned in the National List of Essential Medicines (NLEM) 2022, while 934 (50.8%) were included in the Haryana state essential medicines list (2013-2014). The IRDP was calculated as 3.86. The mean (SD) completeness score of the prescriptions was 10.33 (0.8) (range 5 to 11).

CONCLUSIONS

There was a high incidence of polypharmacy, brand name and non-essential drug prescribing, while antibiotic and injection use were in accordance with WHO standards.

Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study

OBJECTIVES

Prescribing errors can lead to inconvenience, morbidity and mortality. It is therefore crucial to educate doctors to prescribe safely, efficiently and effectively. To create an effective educational programme, it is essential to understand which errors are made and by whom. The aim of this study is to explore if the experience level of the doctor influences how many and which prescribing errors are made in a European academic teaching hospital, where a computerised physician order entry system (CPOE) with a clinical decision support system (CDSS) is exclusively used.

METHODS

Prescriptions for all inpatients in an academic teaching hospital were collected in June 2021. All prescriptions with an alert generated by the CDSS which could not be handled by a pharmacy technician according to local protocol were checked for errors. Identified errors were categorised by type and severity.

RESULTS

A total of 130 538 prescriptions were newly made or altered by doctors. Of these prescriptions, 1914 (1.5%) were retained for a check by the pharmacist. These contained 430 prescribing errors (0.3% of total prescriptions). Doctors not in specialty training and those in specialty training made more prescribing errors than consultants (0.5% and 0.5% vs 0.1%; p<0.001). Doctors in specialty training made relatively more drug-drug interaction errors than consultants (n=31 (16%) vs n=3 (3%), p<0.05). No significant difference was found regarding the severity of the errors.

CONCLUSIONS

Doctors not in specialty training and doctors in specialty training, who are the less experienced doctors, make more prescribing errors than consultants, even with the use of a CPOE combined with CDSS. The type of errors differ between doctors of different experience levels. This finding provides a solid basis for specific additional education to medical students, doctors not in specialty training and doctors in specialty training.

A Snapshot of Potentially Inappropriate Prescriptions upon Pediatric Discharge in Oman

Background: Identifying and quantifying potentially inappropriate prescribing (PIP) practices remains a time-consuming and challenging task, particularly among the pediatric population. In recent years, several valuable tools have been developed and validated for assessing PIP. This study aimed to determine the prevalence of PIP and related risk factors in pediatric patients at a tertiary care hospital in Oman. Materials and Methods: A retrospective study was conducted by reviewing the medical records of pediatric patients (<18 years) from 1 October to 31 December 2019. Potentially inappropriate medication (PIM) and potential prescribing omission (PPO) were assessed using an internationally validated pediatric omission of prescriptions and inappropriate prescriptions (POPI) tool. Results: A total of 685 patients were included; 57.5% were male, and 30.5% had at least one comorbidity. Polypharmacy was identified in 70.2% of these patients, with a median of 2 (1−3) medications. PIM was observed in 20.4% of the cohort, with the highest in ENT-pulmonary disease (30.5%), followed by dermatological disorders (28.6%). PPO was identified in 6.9% of the patients with digestive and neuropsychiatric disorders, with the highest rate of 54% and 24%, respectively. Age (p = 0.006), number of medications (p = 0.034), and prescriber rank (p = 0.006) were identified as significant predictors of PIM, whereas age (p = 0.044) was the only significant predictor for PPO. Conclusions: The rates of PIM and PPO were high in this study population. In light of these findings, educational and interventional activities and programs are needed.

Burnout among pharmacy professionals in Qatar: A cross-sectional study

Background

Pharmacists’ roles and responsibilities have expanded in the modern pharmacy profession, and the expectations from pharmacists have increased. This has been associated with new psychological challenges and emotional stress that can induce burnout.

Objective

To determine the prevalence of burnout syndrome and factors associated with burnout among pharmacy professionals in the healthcare system in Qatar.

Methods

This institutional-based cross-sectional study was conducted on 850 pharmacy professionals within Hamad Medical Corporation (HMC) in Qatar. Convenience sampling was followed. The survey utilized the Maslach Burnout Inventory (MBI) Toolkit™ for Medical Personnel and a modified version of the Astudillo and Mendinueta questionnaire. Statistical analyses were performed using Stata version 16 for Windows and SAS Studio 3.8 (Enterprise Edition). P-value of less than 0.05 was considered significant.

Results

One hundred ninety-four pharmacy professionals (23%) responded to the survey. The prevalence of burnout was 19.7% [95% Confidence interval (CI); 13.8% - 26.8%] among 142 respondents who completed MBI questionnaire and 17.3% [95% CI; 11.7%-24.2%] among 139 respondents who completed Astudillo Mendinueta questionnaire. The most commonly reported factors that may lead to burnout were: tension and lack of organization in teamwork (59.6%), lack of recognition of or indifference to effort from patients, superiors, and colleagues (58.2%), and demanding and challenging patients and family members (56.7%). Multiple regression analysis showed that overtime working hours per month is independently associated with a higher risk of burnout [odds ratio (OR), 1.57; 95% CI, 1.15–2.14 for each 10-hours increase in monthly overtime, P = 0.005], while non-Arab ethnicity is associated with lower risk of burnout [OR, 0.27; 95% CI, 0.1–0.75; P = 0.012].

Conclusions

There is a relatively low prevalence of burnout syndrome among health-system pharmacy professionals in Qatar. Overtime working hours and Arab ethnicity are independently associated with burnout.

Study on Prescription Audit from a Rural Tertiary Care Hospital in North India

Evidence concerning prescription audits conducted in developing countries like India is scarce, especially from the rural parts of the country. Therefore, the present prescription audit was undertaken in a rural tertiary care hospital to investigate prescriptions for their completeness, in format of prescription, legibility of writing and it was assessed against the World Health Organization (WHO) recommendation of core indicators for prescription writing in order to investigate the rational usage of drugs. A total of 200 prescriptions were randomly selected, irrespective of clinical departments, patient characteristics and diagnosis over a period of six months. All the prescriptions were prospectively analyzed and conferred to an assessment of the quality of prescribing practice, general details, medical components, WHO core drug use indicators and legibility. Amongst the 200 prescriptions precisely monitored, we found that 100% prescriptions had general details of the patients such as name, age, gender, OPD/IPD registration number, hospital name & address and consulting unit/department. While evaluating the handwriting of the doctors, 83.5% (177/200) of the prescriptions had legible handwriting, wherein the degree of legibility showed 68.5% (137/200) prescriptions with easy legibility, 20% (40/200) difficult legibility while 11.5% (23/200) were illegible. Along with the different types of drugs obtained from the selected prescriptions, we found that antibiotics were prescribed in 51.5% (103/200) of the prescriptions. A prescription audit is a good tool to systemically review the day to day work, maintenance of records and assessment of accuracy of the diagnosis given by doctors and also the outcome of the treatment received.

Associations of physicians' prescribing experience, work hours, and workload with prescription errors

OBJECTIVE

We aimed to assess associations of physician's work overload, successive work shifts, and work experience with physicians' risk to err.

MATERIALS AND METHODS

This large-scale study included physicians who prescribed at least 100 systemic medications at Sheba Medical Center during 2012-2017 in all acute care departments, excluding intensive care units. Presumed medication errors were flagged by a high-accuracy computerized decision support system that uses machine-learning algorithms to detect potential medication prescription errors. Physicians' successive work shifts (first or only shift, second, and third shifts), workload (assessed by the number of prescriptions during a shift) and work-experience, as well as a novel measurement of physicians' prescribing experience with a specific drug, were assessed per prescription. The risk to err was determined for various work conditions.

RESULTS

1 652 896 medical orders were prescribed by 1066 physicians; The system flagged 3738 (0.23%) prescriptions as erroneous. Physicians were 8.2 times more likely to err during high than normal-low workload shifts (5.19% vs 0.63%, P < .0001). Physicians on their third or second successive shift (compared to a first or single shift) were more likely to err (2.1%, 1.8%, and 0.88%, respectively, P < .001). Lack of experience in prescribing a specific medication was associated with higher error rate (0.37% for the first 5 prescriptions vs 0.13% after over 40, P < .001).

DISCUSSION

Longer hours and less experience in prescribing a specific medication increase risk of erroneous prescribing.

CONCLUSION

Restricting successive shifts, reducing workload, increasing training and supervision, and implementing smart clinical decision support systems may help reduce prescription errors.

Prescribing errors among adult patients in a large tertiary care system in Saudi Arabia

BACKGROUND

Multiple studies have investigated medication errors in hospitals in Saudi Arabia; however, prevalence data on prescribing errors and associated factors remains uncertain.

OBJECTIVE

Assess the prevalence, type, severity, and factors associated with prescribing errors.

DESIGN

Retrospective database review.

SETTING

Large tertiary care setting in Riyadh.

PATIENTS AND METHODS

We described and analyzed data related to prescribing errors in adults (>14 years of age) from the Medication Error Electronic Report Forms database for the two-year period from January 2017 to December 2018.

MAIN OUTCOME MEASURE

The prevalence of prescribing errors and associated factors among adult patients.

SAMPLE SIZE

315 166 prescriptions screened.

RESULTS

Of the total number of inpatient and outpatient prescriptions screened, 4934 prescribing errors were identified for a prevalence of 1.56%. The most prevalent types of prescribing errors were improper dose (n=1516; 30.7%) and frequency (n=987; 20.0%). Two-thirds of prescribing errors did not cause any harm to patients. Most prescribing errors were made by medical residents (n=2577; 52%) followed by specialists (n=1629; 33%). Prescribing errors were associated with a lack of documenting clinical information (adjusted odds ratio: 14.1; 95% CI 7.7-16.8, P<.001) and prescribing anti-infective medications (adjusted odds ratio 2.9; 95% CI 1.3-5.7, P<.01).

CONCLUSION

Inadequate documentation in electronic health records and prescribing of anti-infective medications were the most common factors for predicting prescribing errors. Future studies should focus on testing innovative measures to control these factors and their impact on minimizing prescribing errors.

LIMITATIONS

Polypharmacy was not considered; the data are from a single healthcare system.

CONFLICT OF INTEREST

None.

Collaborative Medication Reviews to Identify Inappropriate Prescribing in Pre-Admission Medications at Emergency Department Short-Term Ward

PURPOSE

Collaborative medication reviews (CMR) have been shown to reduce inappropriate prescribing (IP) in various settings. This study aimed at describing a CMR practice in an emergency department (ED) short-term ward in Finland to investigate IP in pre-admission medications.

PATIENTS AND METHODS

Pre-admission medications were collaboratively reviewed for all the adult ED admissions within a 5-month study period in 2016. Types of IP were inductively categorized, and descriptive statistics were used to show the incidence and type of IP events.

RESULTS

The pre-admission medications of 855 adult ED patients were reviewed by the pharmacist, with 113 IP events identified in 83 (9.7%) of the patients. The majority (81%, n=67) of these patients were older adults (≥65 years). Of these 94 IP events identified in 67 older patients, 58 (62%) were confirmed by the ED physicians. The following 3 main categories were inductively developed for the types of identified and confirmed IP events: 1) Misprescribing (prescription of medications that significantly increase the risk of adverse drug events); 2) Overprescribing (prescription of medications for which no clear clinical indications exist); and 3) Underprescribing (omission of potentially beneficial medications that are clinically indicated for treatment or prevention of a disease). Misprescribing was the most common type of IP identified (79% of the identified and 72% confirmed IP events). Benzodiazepines (29%) and antidepressants (28%) were involved in 33 out of 58 (57%) confirmed IP events. Medications with strong anticholinergic effects were involved in 19% of the confirmed IP events.

CONCLUSION

The CMR practice was able to identify IP in pre-admission medications of about one-tenth of ED patients. Older patients using benzodiazepines and drugs with strong anticholinergic effects should be paid special attention to ED admissions.

Psychometric Testing of Errors of Care Omission Survey: A New Tool on Patient Safety in Primary Care

OBJECTIVE

The aim of the study was to evaluate the psychometric properties of a newly developed survey tool measuring omissions in primary care.

METHODS

The Errors of Care Omission Survey (ECOS) is the only known tool to measure critical omissions ("errors") in primary care from the perspectives of primary care providers (PCPs), both physicians and nurse practitioners. The tool has 31 items grouped into the following four subscales: Self-Management Support, Follow-up, Emotional Health Support, and Care Integration. A cross-sectional survey design was used to mail the tool to PCPs and 582 PCPs in one state in the U.S. completed and returned the survey. Exploratory factor analysis with target rotation was carried out. Internal consistency reliability of identified subscales was investigated.

RESULTS

Four factors emerged representing domains of omissions in primary care. The original Follow-up and Care Integration subscales were retained. The items on Self-Management Support and Emotional Health Support subscales loaded differently on two factors, which were labeled Patient Self-Management and Family Engagement subscales, suggesting that conceptually PCPs separate patient and family involvement in patient care. Seven poorly performing or redundant items were removed. The remaining 24 items measure patient self-management, family engagement, follow-up, and care integration domains of omissions in primary care. The ECOS subscales have acceptable internal consistency reliability with Cronbach's α ranging from 0.90 to 0.97.

CONCLUSIONS

The ECOS can be used in primary care to identify critical omissions, so actions can be taken by clinicians and administrators to prevent them before they result in patient harm. Further testing of the ECOS is recommended with diverse samples.

Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting

BACKGROUND

Prescribing errors are prevalent in hospital settings with provision of feedback recommended to support prescribing of doctors. Feedback on prescribing has been described as feasible and valued but limited by doctors, with pharmacists described as credible facilitators of prescribing feedback. Evidence supporting prescribing feedback has been limited to date. A formalised programme of pharmacist-led prescribing error feedback was designed and implemented to support prescribers.

OBJECTIVE

To evaluate the impact of a prescribing feedback intervention on prescribing error rates and frequency of prescribing error severity and type.

METHOD

Prospective prescribing audits were undertaken across sixteen hospital wards in a UK teaching hospital over a five day period with 36 prescribers in the intervention group and 41 in the control group. The intervention group received pharmacist-led, individualised constructive feedback on their prescribing, whilst the control group continued with existing practice. Prescribing was re-audited after three months. Prescribing errors were classified by type and severity and data were analysed using relevant statistical tests.

RESULTS

A total of 5191 prescribed medications were audited at baseline and 5122 post-intervention. There was a mean prescribing error rate of 25.0% (SD 16.8, 95% CI 19.3 to 30.7) at baseline and 6.7% (SD 9.0, 95% CI 3.7 to 9.8) post-intervention for the intervention group, and 19.7% (SD 14.5, 95% CI 15.2 to 24.3) at baseline and 25.1% (SD 17.0, 95% CI 19.8 to 30.6) post-intervention for the control group with a significant overall change in prescribing error rates between groups of 23.7% (SD 3.5, 95% CI, -30.6 to -16.8), t(75) = -6.9, p < 0.05. The frequency of each error type and severity rating was reduced in the intervention group, whilst the error frequency of some error types and severity increased in the control group.

CONCLUSION

Pharmacist-led prescribing feedback has the potential to reduce prescribing errors and improve prescribing outcomes and patient safety.

A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system

Background Computerised Physician Order Entry (CPOE) is considered to enhance the safety of prescribing. However, it can have unintended consequences and new forms of prescribing error have been reported. Objective The aim of this study was to explore the causes and contributing factors associated with prescribing errors reported by multidisciplinary prescribers working within a CPOE system. Main Outcome Measure Multidisciplinary prescribers experience of prescribing errors in an CPOE system. Method This qualitative study was conducted in a hospital with a well-established CPOE system. Semi-structured qualitative interviews were conducted with prescribers from the professions of pharmacy, nursing, and medicine. Interviews analysed using a mixed inductive and deductive approach to develop a framework for the causes of error. Results Twenty-three prescribers were interviewed. Six main themes influencing prescribing were found: the system, the prescriber, the patient, the team, the task of prescribing and the work environment. Prominent issues related to CPOE included, incorrect drug name picking, default auto-population of dosages, alert fatigue and remote prescribing. These interacted within a complex prescribing environment. No substantial differences in the experience of CPOE were found between the professions. Conclusion Medical and non-medical prescribers have similar experiences of prescribing errors when using CPOE, aligned with existing published literature about medical prescribing. Causes of electronic prescribing errors are multifactorial in nature and prescribers describe how factors interact to create the conditions errors. While interventions should focus on direct CPOE issues, such as training and design, socio-technical, and environmental aspects of practice remain important.

Economic analysis of the prevalence and clinical and economic burden of medication error in England

OBJECTIVES

To provide national estimates of the number and clinical and economic burden of medication errors in the National Health Service (NHS) in England.

METHODS

We used UK-based prevalence of medication errors (in prescribing, dispensing, administration and monitoring) in primary care, secondary care and care home settings, and associated healthcare resource use, to estimate annual number and burden of errors to the NHS. Burden (healthcare resource use and deaths) was estimated from harm associated with avoidable adverse drug events (ADEs).

RESULTS

We estimated that 237 million medication errors occur at some point in the medication process in England annually, 38.4% occurring in primary care; 72% have little/no potential for harm and 66 million are potentially clinically significant. Prescribing in primary care accounts for 34% of all potentially clinically significant errors. Definitely avoidable ADEs are estimated to cost the NHS £98 462 582 per year, consuming 181 626 bed-days, and causing/contributing to 1708 deaths. This comprises primary care ADEs leading to hospital admission (£83.7 million; causing 627 deaths), and secondary care ADEs leading to longer hospital stay (£14.8 million; causing or contributing to 1081 deaths).

CONCLUSIONS

Ubiquitous medicines use in health care leads unsurprisingly to high numbers of medication errors, although most are not clinically important. There is significant uncertainty around estimates due to the assumption that avoidable ADEs correspond to medication errors, data quality, and lack of data around longer-term impacts of errors. Data linkage between errors and patient outcomes is essential to progress understanding in this area.

Assessment of burnout within a health-system pharmacy department

Purpose

Workplace-related burnout is a state of mental and physical exhaustion caused by one’s professional life. Literature demonstrates the link between physician burnout and serious consequences (reduced productivity, medical errors, and clinician suicide), but assessment of burnout in other healthcare professions is limited, especially in pharmacy. A quality improvement study was conducted to quantify burnout in a diverse health-system pharmacy department and identify potential strategies to improve well-being.

Methods

A survey was distributed to assess the perception and drivers of burnout within a health-system pharmacy. All associates received a survey comprised of the Maslach Burnout Inventory (MBI), demographic questions, and items affording respondents the opportunity to list stressors and potential solutions. Email reminders were sent weekly and site visits were conducted to encourage survey completion. Results were analyzed via descriptive statistics.

Results

Two hundred seventy-seven associates completed the survey (response rate, 40.5%). Seventy percent of those participants were experiencing moderate to high levels of burnout, with survey results indicating moderate levels of personal accomplishment and emotional exhaustion and low levels of depersonalization; there were no statistically significant differences in mean MBI scores by shift type, hours worked per week, or years of service. There were statistically significant differences in scores for personal accomplishment between males and females, as well as among positions and regions (P &lt; 0.05). Participants identified issues related to workflow, control, and community as the greatest contributors to stress.

Conclusion

The diverse staff of a health-system pharmacy department reported a moderate amount of burnout, with the greatest variation in the dimension of personal accomplishment. The mitigation strategies most commonly cited were staffing/workflow adjustments and creating a culture of well-being.

Prescribing errors in pediatric outpatient department at a tertiary care hospital in Malaysia

Background Prescribing errors in children are common due to individualization of dosage regimen. It potentially has a great impact especially in this vulnerable population. Objective To determine the prevalence and common types of prescribing errors in a Malaysian pediatric outpatient department and to determine the factors contributing to prescribing errors. Setting Pediatric Outpatient Department and Outpatient Pharmacy at a tertiary care hospital in Malaysia. Method This is a prospective, cross sectional observational study where all new prescriptions received by the outpatient pharmacy from patients attending pediatric out-patient clinic were included for analysis. Descriptive statistics and logistic regression were used to analyze the data. Main outcome measure Frequency, types, potential clinical consequences and contributing factors of prescribing errors. Results Two hundred and fifty new prescriptions with 493 items were analyzed. There were 13 per 100 prescriptions with at least one prescribing error and 7.3% of the total items were prescribed incorrectly. The most common types of prescribing error were, an ambiguous prescription (61.1%) followed by an unrecommended dose regimen (13.9%). Logistic regression analysis showed that the risk of a prescribing error significantly increased when the prescription was written by a house officer (OR 4.72, p = 0.029). Errors were judged to be potentially non-significant (33.3%), significant (36.1%), or serious (30.6%). Conclusion The experience of prescribers is an important factor that contributes to prescribing errors in pediatrics. Many of the errors made were potentially serious and may impact on the patients' well-being.

Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation

Aims

To develop and evaluate a feasible, authentic pharmacist‐led prescribing feedback intervention for doctors‐in‐training, to reduce prescribing errors.

Methods

This was a mixed methods study. Sixteen postgraduate doctors‐in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi‐structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically.

Results

During the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P < .0001). Pharmacist‐led video‐stimulated prescribing feedback was feasible and positively received by participants, who appreciated the reinforcement of good practice as well as the opportunity to reflect on and improve practice.

Conclusions

Feedback to doctors‐in‐training tends to be infrequent and often negative, but this feasible feedback strategy significantly reduced prescribing errors and was well received by the target audience as a supportive developmental approach.

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

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

A prescription audit using the World Health Organization-recommended core drug use indicators in a rural hospital of Delhi

INTRODUCTION

The inappropriate use of drugs is a global health problem, especially in developing country like India. Irrational prescriptions have an ill effect on health as well as health-care expenditure. Prescription auditing is an important tool to improve the quality of prescriptions, which in turn improves the quality of health care provided. The present study was conducted to investigate the rational use of drugs for completeness, legibility, and against the World Health Organization (WHO)-recommended core drug use indicators.

MATERIALS AND METHODS

A cross-sectional, outpatient department-based study was carried out in a rural hospital of Delhi wherein 120 prescriptions were randomly sampled, irrespective of patient characteristics and diagnosis over a period of 1 month. All the prescriptions were analyzed for general details, medical components, and WHO core drug use indicators. The data obtained were summed up and presented as descriptive statistics using the Microsoft Excel and were analyzed using SPSS version 16.

RESULTS

All the prescriptions had general details mentioned in it. The diagnosis was mentioned in 64.2% of prescriptions, and 85.8% of drugs were prescribed by generic name. An average of 3.02 drugs per encounter was prescribed. The average consultation time and dispensing time were 2.8 min and 1.2 min, respectively. Only half of the patients had correct knowledge of dose.

CONCLUSIONS

Our study highlights the need to train our prescribing doctors on writing rational prescriptions for quality improvement.

Antibiotic Prescribing Practices and Errors among Hospitalized Pediatric Patients Suffering from Acute Respiratory Tract Infections: A Multicenter, Cross-Sectional Study in Pakistan

Background and objective: The noncompliance of treatment guidelines by healthcare professionals, along with physiological variations, makes the pediatric population more prone to antibiotic prescribing errors. The present study aims to evaluate the prescribing practices and errors of the most frequently prescribed antibiotics among pediatric patients suffering from acute respiratory tract infections who had different lengths of stay (LOS) in public hospitals. Methods: A retrospective, cross-sectional study was conducted in five tertiary-care public hospitals of Lahore, Pakistan, between 1 January 2017 and 30 June 2017. The study population consisted of pediatric inpatients aged 0 to 9 years. Results: Among the 11,892 pediatric inpatients, 82.8% were suffering from lower acute respiratory tract infections and had long LOS (53.1%) in hospital. Penicillins (52.4%), cephalosporins (16.8%), and macrolides (8.9%) were the most frequently prescribed antibiotics. Overall, 40.8% of the cases had antibiotic prescribing errors related to wrong dose (19.9%), wrong frequency (18.9%), and duplicate therapy (18.1%). Most of these errors were found in the records of patients who had long LOS in hospital (53.1%). Logistic regression analysis revealed that the odds of prescribing errors were lower in female patients (OR = 0.6, 95% CI = 0.1⁻0.9, p-value = 0.012). Patients who were prescribed with ≥3 antibiotics per prescription (OR = 1.724, 95% CI = 1.1⁻2.1, p-value = 0.020), had long LOS (OR = 12.5, 95% CI = 10.1⁻17.6, p-value < 0.001), and were suffering from upper respiratory tract infections (URTI) (OR = 2.8, 95% CI = 1.7⁻3.9, p-value < 0.001) were more likely to experience prescribing errors. Conclusion: Antibiotics were commonly prescribed to patients who had long LOS. Prescribing errors (wrong dose, wrong frequency, and duplicate therapy) were commonly found in cases of lower respiratory tract infections (LRTIs), especially among those who had prolonged stay in hospital.

Evaluation of Prescriptions Dispensed in the Outpatient Pharmacies of a University Teaching Hospital in Moshi, Kilimanjaro Region, Tanzania: A Cross-Sectional Study

BACKGROUND

Prescriptions written in daily medical practice are associated with increasing numbers of prescription writing errors. Both omission and commission errors are encountered and caused by prescribers of different cadres. Prescribing errors are associated with adverse drug events (ADEs), which are harmful to patients. This study aimed to determine the common prescription errors, the categories of prescribers who commit prescription errors, and the most prescribed drugs in the outpatient pharmacies in general practice at Kilimanjaro Christian Medical Centre (KCMC).

METHODS

A prospective cross-sectional descriptive study was conducted at KCMC, a referral and teaching university hospital. All prescription dispensed on 2 June 2017 from the hospital's 2 outpatient pharmacies were reviewed, and our analysis determined the different types of prescription errors. A form designed by the authors was used to collect data from the prescription forms.

RESULTS

A total of 242 prescriptions were studied, and the most common omission errors were missing patients' weight (n=231, 95.5%), missing patients' address (n=213, 88.0%), missing drug dosage (n=159, 67.1%), and commission errors were due to wrong drug strength (n=10, 2.0%). Intern doctors were leading in writing prescriptions with errors (n=352, 25.6%), followed by residents (n=199, 14.5%), registrar doctors (n=167, 12.1%), and specialists (n=45, 3.3%). The most commonly prescribed drugs were antibiotics (n=120, 17.3%), antihypertensives (n=81, 11.7%), and analgesics (n=86, 12.4%).

CONCLUSION

There were significant prescription errors at the study site, hence an intervention is needed to improve skills of prescribers. Educational interventions can substantially contribute to minimising such errors. Initaiting programmes and short courses on prescription writing before medical internship at the health facility might also be helpful.

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

Objectives

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

Design

A prospective cross-sectional, observational study.

Setting

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

Participants

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

Interventions

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

Main Outcome Measures

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

Results

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

Conclusions

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

Prescripción inadecuada de medicamentos: aportaciones de los paradigmas científicos a su conocimiento

Resumen Se realizó una revisión narrativa con análisis temático sobre las aportaciones de los paradigmas científicos al conocimiento de la prescripción inadecuada de medicamentos. Se buscaron artículos de acceso abierto indexados en PubMed© entre 2010-2014, y se sistematizó información sobre el paradigma, tipo de publicación, perspectiva teórica, objetivo, método y resultados. De los 992 artículos encontrados, se seleccionaron 118, y se tomó una muestra propositiva de 15, según su diseño, representando los cuatro paradigmas. Los artículos positivistas reportaron prevalencia, factores asociados, efectividad de intervenciones y criterios de evaluación; los interpretativos explicaron las causas del problema según los involucrados; los críticos denunciaron la influencia de la industria farmacéutica; y el participativo abordó el problema secundariamente y lo solucionó en un escenario para una enfermedad y grupo farmacológico específicos. Se concluyó que la prescripción inadecuada de medicamentos como problema de investigación en salud pública recibe aportes de los cuatro paradigmas, con dominio del positivismo, lo que se atribuye al carácter paradigmático de la ciencia desde la que se le aborda habitualmente, y que una perspectiva multi-paradigmática es el mejor abordaje.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors Associated With Burnout Among US Hospital Clinical Pharmacy Practitioners: Results of a Nationwide Pilot Survey

Background: In health care, burnout has been defined as a psychological process whereby human service professionals attempting to positively impact the lives of others become overwhelmed and frustrated by unforeseen job stressors. Burnout among various physician groups who primarily practice in the hospital setting has been extensively studied; however, no evidence exists regarding burnout among hospital clinical pharmacists. Objective: The aim of this study was to characterize the level of and identify factors independently associated with burnout among clinical pharmacists practicing in an inpatient hospital setting within the United States. Methods: We conducted a prospective, cross-sectional pilot study utilizing an online, Qualtrics survey. Univariate analysis related to burnout was conducted, with multivariable logistic regression analysis used to identify factors independently associated with the burnout. Results: A total of 974 responses were analyzed (11.4% response rate). The majority were females who had practiced pharmacy for a median of 8 years. The burnout rate was high (61.2%) and largely driven by high emotional exhaustion. On multivariable analysis, we identified several subjective factors as being predictors of burnout, including inadequate administrative and teaching time, uncertainty of health care reform, too many nonclinical duties, difficult pharmacist colleagues, and feeling that contributions are underappreciated. Conclusions: The burnout rate of hospital clinical pharmacy providers was very high in this pilot survey. However, the overall response rate was low at 11.4%. The negative effects of burnout require further study and intervention to determine the influence of burnout on the lives of clinical pharmacists and on other health care-related outcomes.

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

PURPOSE OF THE STUDY

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

The incidence and severity of errors in pharmacist-written discharge medication orders

Background Errors in discharge prescriptions are problematic. When hospital pharmacists write discharge prescriptions improvements are seen in the quality and efficiency of discharge. There is limited information on the incidence of errors in pharmacists’ medication orders. Objective To investigate the extent and clinical significance of errors in pharmacist-written discharge medication orders. Setting 1000-bed teaching hospital in London, UK. Method Pharmacists in this London hospital routinely write discharge medication orders as part of the clinical pharmacy service. Convenient days, based on researcher availability, between October 2013 and January 2014 were selected. Pre-registration pharmacists reviewed all discharge medication orders written by pharmacists on these days and identified discrepancies between the medication history, inpatient chart, patient records and discharge summary. A senior clinical pharmacist confirmed the presence of an error. Each error was assigned a potential clinical significance rating (based on the NCCMERP scale) by a physician and an independent senior clinical pharmacist, working separately. Main outcome measure Incidence of errors in pharmacist-written discharge medication orders. Results 509 prescriptions, written by 51 pharmacists, containing 4258 discharge medication orders were assessed (8.4 orders per prescription). Ten prescriptions (2%), contained a total of ten erroneous orders (order error rate—0.2%). The pharmacist considered that one error had the potential to cause temporary harm (0.02% of all orders). The physician did not rate any of the errors with the potential to cause harm. Conclusion The incidence of errors in pharmacists’ discharge medication orders was low. The quality, safety and policy implications of pharmacists routinely writing discharge medication orders should be further explored.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

How prepared are UK medical graduates for practice? A rapid review of the literature 2009-2014

OBJECTIVE

To understand how prepared UK medical graduates are for practice and the effectiveness of workplace transition interventions.

DESIGN

A rapid review of the literature (registration #CRD42013005305).

DATA SOURCES

Nine major databases (and key websites) were searched in two timeframes (July-September 2013; updated May-June 2014): CINAHL, Embase, Educational Resources Information Centre, Health Management Information Consortium, MEDLINE, MEDLINE in Process, PsycINFO, Scopus and Web of Knowledge.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary research or studies reporting UK medical graduates' preparedness between 2009 and 2014: manuscripts in English; all study types; participants who are final-year medical students, medical graduates, clinical educators, patients or NHS employers and all outcome measures.

DATA EXTRACTION

At time 1, three researchers screened manuscripts (for duplicates, exclusion/inclusion criteria and quality). Remaining 81 manuscripts were coded. At time 2, one researcher repeated the process for 2013-2014 (adding six manuscripts). Data were analysed using a narrative synthesis and mapped against Tomorrow's Doctors (2009) graduate outcomes.

RESULTS

Most studies comprised junior doctors' self-reports (65/87, 75%), few defined preparedness and a programmatic approach was lacking. Six themes were highlighted: individual skills/knowledge, interactional competence, systemic/technological competence, personal preparedness, demographic factors and transitional interventions. Graduates appear prepared for history taking, physical examinations and some clinical skills, but unprepared for other aspects, including prescribing, clinical reasoning/diagnoses, emergency management, multidisciplinary team-working, handover, error/safety incidents, understanding ethical/legal issues and ward environment familiarity. Shadowing and induction smooth transition into practice, but there is a paucity of evidence around assistantship efficacy.

CONCLUSIONS

Educational interventions are needed to address areas of unpreparedness (eg, multidisciplinary team-working, prescribing and clinical reasoning). Future research in areas we are unsure about should adopt a programmatic and rigorous approach, with clear definitions of preparedness, multiple stakeholder perspectives along with multisite and longitudinal research designs to achieve a joined-up, systematic, approach to understanding future educational requirements for junior doctors.

Pharmacist independent prescribing in secondary care: opportunities and challenges

In recent years a number of countries have extended prescribing rights to pharmacists in a variety of formats. The latter includes independent prescribing, which is a developing area of practice for pharmacists in secondary care. Potential opportunities presented by wide scale implementation of pharmacist prescribing in secondary care include improved prescribing safety, more efficient pharmacist medication reviews, increased scope of practice with greater pharmacist integration into acute patient care pathways and enhanced professional or job satisfaction. However, notable challenges remain and these need to be acknowledged and addressed if a pharmacist prescribing is to develop sufficiently within developing healthcare systems. These barriers can be broadly categorised as lack of support (financial and time resources), medical staff acceptance and the pharmacy profession itself (adoption, implementation strategy, research resources, second pharmacist clinical check). Larger multicentre studies that investigate the contribution of hospital-based pharmacist prescribers to medicines optimisation and patient-related outcomes are still needed. Furthermore, a strategic approach from the pharmacy profession and leadership is required to ensure that pharmacist prescribers are fully integrated into future healthcare service and workforce strategies.

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

Introduction

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

Objective

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

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.

Pharmacist's review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)

PURPOSE

The purpose was to describe clinical pharmacist interventions across a range of critical care units (CCUs) throughout the United Kingdom, to identify CCU medication error rate and prescription optimization, and to identify the type and impact of each intervention in the prevention of harm and improvement of patient therapy.

MATERIALS AND METHODS

A prospective observational study was undertaken in 21 UK CCUs from November 5 to 18, 2012. A data collection web portal was designed where the specialist critical care pharmacist reported all interventions at their site. Each intervention was classified as medication error, optimization, or consult. In addition, a clinical impact scale was used to code the interventions. Interventions were scored as low impact, moderate impact, high impact, and life saving. The final coding was moderated by blinded independent multidisciplinary trialists.

RESULTS

A total of 20517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. This resulted in an overall intervention rate of 16.1%: 6.8% were classified as medication errors, 8.3% optimizations, and 1.0% consults. The interventions were classified as low impact (34.0%), moderate impact (46.7%), and high impact (19.3%); and 1 case was life saving. Almost three quarters of interventions were to optimize the effectiveness of and improve safety of pharmacotherapy.

CONCLUSIONS

This observational study demonstrated that both medication error resolution and pharmacist-led optimization rates were substantial. Almost 1 in 6 prescriptions required an intervention from the clinical pharmacist. The error rate was slightly lower than an earlier UK prescribing error study (EQUIP). Two thirds of the interventions were of moderate to high impact.

An individual patient data meta-analysis on factors associated with adverse drug events in surgical and non-surgical inpatients

AIM

The incidence of adverse drug events (ADEs) in surgical and non-surgical patients may differ. This individual patient data meta-analysis (IPDMA) identifies patient characteristics and types of medication most associated with patients experiencing ADEs and suggests target areas for reducing harm and implementing focused interventions.

METHODS

Authors of eligible studies on preventable ADEs (pADEs) were approached for collaboration. For assessment of differences among (non-)surgical patients and identification of associated factors descriptive statistics, Pearson chi-square, Poisson and logistic regression analyses were performed. For identification of high risk drugs (HRDs), a model was developed based on frequency, severity and preventability of medication related to ADEs.

RESULTS

Included were 5367 patients from four studies. Patients aged ≥ 77 years experienced more ADEs and pADEs compared with patients aged ≤ 52 years (odds ratios (OR) 2.12 (95% CI 1.70, 2.65) and 2.55 (95% CI 1.70, 3.84), respectively, both P < 0.05). Polypharmacy on admission also increased the risk of ADEs (OR 1.21 (95% CI 1.03, 1.44), P < 0.05) and pADEs (OR 1.85 (95% CI 1.34, 2.56), P < 0.05). pADEs were associated with more severe harm than non-preventable ADEs (54% vs. 32%, P < 0.05). The top five HRDs were antibiotics, sedatives, anticoagulants, diuretics and antihypertensives. Events associated with HRDs included diarrhoea or constipation, abnormal liver function test and central nervous system events. Most pADEs resulted from prescribing errors (90%).

CONCLUSION

Elderly patients with polypharmacy on admission and receiving antibiotics, sedatives, anticoagulants, diuretics or antihypertensives were more prone to experiencing ADEs. Efficiency in prevention of ADEs may be improved by targeted vigilance systems for alertness of physicians and pharmacists.

Analysis of Out Door Patients' Prescriptions According to World Health Organization (WHO) Prescribing Indicators Among Private Hospitals in Western India

BACKGROUND

Prescription is document through which doctor, patient and pharmacist are communicated. Many a times if these documents are not properly written or misinterpreted it can affect management of patients. WHO established prescribing indicators to analyse prescription and promoted rational use of drugs and better management of patients.

AIM

To study the prescription pattern according to WHO prescribing indicators among private hospitals.

SETTINGS AND DESIGN

The observational, prospective study carried out at different private hospitals at metro city in Western India to study the prescription pattern among private hospital.

MATERIALS AND METHODS

Study was conducted at different private hospitals of metro city. A total of 250 prescriptions of outdoor patients from various departments of private hospitals were collected for a period of three months (August to October) 2012 and evaluated.

STATISTICAL ANALYSIS

The study was analysed using Z-test.

RESULTS

Patient details like age and gender was not written in all (100%) prescriptions. It was noticed that dose, direction of drug and duration of treatment was not completely written in 90%, 74% and 80% of prescriptions respectively. Abbreviations were used in all (100%) prescriptions. Doctor's medical registration number was mentioned in 0% prescriptions. Total 869 drugs were prescribed in 250 prescriptions. Average number of drug prescribed was 3.38±1.79 (Mean±SD). It was reported that Group II (3 to 4 encoutner) was significantly higher as compared to Group I (less than or equal to 2 encoutner) and Group III( more than four encounter). It was significantly (p<0.05) prescribed brand name prescriptions (93.33%) as compared to generic name prescriptions (6.7%). Percentage of encounter with antibiotics and injections was 54% and 18% respectively. Approximately 70% drugs were prescribed according to Essential Medicine List (EML) of State. Antibiotics accounted 30% of prescribed drugs which was significantly higher as compared to other group of prescribed drugs.

CONCLUSION

Our study revealed that prescription errors were most commonly observed at private hospitals and antibiotics was commonly prescribed in private sector. Therefore, strict policy to good prescribing practice and strict antibiotic policy in outdoor patients are required to promote rational use of drugs.

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.

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.

Cost-effectiveness of an electronic medication ordering system (CPOE/CDSS) in hospitalized patients

INTRODUCTION

Prescribing medication is an important aspect of almost all in-hospital treatment regimes. Besides their obviously beneficial effects, medicines can also cause adverse drug events (ADE), which increase morbidity, mortality and health care costs. Partially, these ADEs arise from medication errors, e.g. at the prescribing stage. ADEs caused by medication errors are preventable ADEs. Until now, medication ordering was primarily a paper-based process and consequently, it was error prone. Computerized Physician Order Entry, combined with basic Clinical Decision Support System (CPOE/CDSS) is considered to enhance patient safety. Limited information is available on the balance between the health gains and the costs that need to be invested in order to achieve these positive effects. Aim of this study was to study the balance between the effects and costs of CPOE/CDSS compared to the traditional paper-based medication ordering.

METHODS

The economic evaluation was performed alongside a clinical study (interrupted time series design) on the effectiveness of CPOE/CDSS, including a cost minimization and a cost-effectiveness analysis. Data collection took place between 2005 and 2008. Analyses were performed from a hospital perspective. The study was performed in a general teaching hospital and a University Medical Centre on general internal medicine, gastroenterology and geriatric wards. Computerized Physician Order Entry, combined with basic Clinical Decision Support System (CPOE/CDSS) was compared to a traditional paper based system. All costs of both medication ordering systems are based on resources used and time invested. Prices were expressed in Euros (price level 2009). Effectiveness outcomes were medication errors and preventable adverse drug events.

RESULTS

During the paper-based prescribing period 592 patients were included, and during the CPOE/CDSS period 603. Total costs of the paper-based system and CPOE/CDSS amounted to €12.37 and €14.91 per patient/day respectively. The Incremental Cost-Effectiveness Ratio (ICER) for medication errors was 3.54 and for preventable adverse drug events 322.70, indicating the extra amount (€) that has to be invested in order to prevent one medication error or one pADE.

CONCLUSIONS

CPOE with basic CDSS contributes to a decreased risk of preventable harm. Overall, the extra costs of CPOE/CDSS needed to prevent one ME or one pADE seem to be acceptable.

Assessment of the knowledge and attitudes of intern doctors to medication prescribing errors in a Nigeria tertiary hospital

CONTEXT

Junior doctors are reported to make most of the prescribing errors in the hospital setting.

AIMS

The aim of the following study is to determine the knowledge intern doctors have about prescribing errors and circumstances contributing to making them.

SETTINGS AND DESIGN

A structured questionnaire was distributed to intern doctors in National Hospital Abuja Nigeria.

SUBJECTS AND METHODS

Respondents gave information about their experience with prescribing medicines, the extent to which they agreed with the definition of a clinically meaningful prescribing error and events that constituted such. Their experience with prescribing certain categories of medicines was also sought.

STATISTICAL ANALYSIS USED

Data was analyzed with Statistical Package for the Social Sciences (SPSS) software version 17 (SPSS Inc Chicago, Ill, USA). Chi-squared analysis contrasted differences in proportions; P < 0.05 was considered to be statistically significant.

RESULTS

The response rate was 90.9% and 27 (90%) had <1 year of prescribing experience. 17 (56.7%) respondents totally agreed with the definition of a clinically meaningful prescribing error. Most common reasons for prescribing mistakes were a failure to check prescriptions with a reference source (14, 25.5%) and failure to check for adverse drug interactions (14, 25.5%). Omitting some essential information such as duration of therapy (13, 20%), patient age (14, 21.5%) and dosage errors (14, 21.5%) were the most common types of prescribing errors made. Respondents considered workload (23, 76.7%), multitasking (19, 63.3%), rushing (18, 60.0%) and tiredness/stress (16, 53.3%) as important factors contributing to prescribing errors. Interns were least confident prescribing antibiotics (12, 25.5%), opioid analgesics (12, 25.5%) cytotoxics (10, 21.3%) and antipsychotics (9, 19.1%) unsupervised.

CONCLUSIONS

Respondents seemed to have a low awareness of making prescribing errors. Principles of rational prescribing and events that constitute prescribing errors should be taught in the practice setting.

The use and functionality of electronic prescribing systems in english acute NHS trusts: a cross-sectional survey

Objectives

To describe current use of electronic prescribing (EP) in English acute NHS hospital trusts, and the use of multiple EP systems within the same hospital.

Design

Descriptive cross-sectional postal survey.

Setting

Acute NHS hospital trusts in England.

Participants

The survey was sent to chief pharmacists in all acute English NHS hospital trusts in 2011. Where trusts comprised multiple hospitals, respondents were asked to complete the questionnaire for their main acute hospital.

Main Outcome Measures

Prevalence of EP use in acute NHS hospitals; number of different EP systems in each hospital; stages of the patient pathway in which EP used; extent of deployment across the hospital; comprehensiveness regarding the drugs prescribed; decision support functionalities used.

Results

We received responses from 101 trusts (61%). Seventy (69%) respondent hospitals had at least one form of EP in use. More than half (39;56%) of hospitals with EP had more than one system in use, representing 60 different systems. The most common were systems used only for discharge prescribing, used in 48 (48% of respondent hospitals). Specialist chemotherapy EP systems were second most common (34; 34%). Sixteen specialist inpatient systems were used across 15 hospitals, most commonly in adult critical care. Only 13 (13%) respondents used inpatient electronic prescribing across all adult medical and surgical wards. Overall, 24 (40%) systems were developed ‘in-house’. Decision support functionality varied widely.

Conclusions

It is UK government policy to encourage the adoption of EP in hospitals. Our work shows that EP is prevalent in English hospitals, although often in limited clinical areas and for limited types of prescribing. The diversity of systems in use, often within the same hospital, may create challenges for staff training and patient safety.