Impact of a standard medication chart on prescribing errors: a before-and-after audit

Differences in medication reconciliation interventions between six hospitals: a mixed method study

Background

Although medication reconciliation (MedRec) is mandated and effective in decreasing preventable medication errors during transition of care, hospitals implement MedRec differently.

Objective

Quantitatively compare the number and type of MedRec interventions between hospitals upon admission and discharge, followed by a qualitative analysis on potential reasons for differences.

Methods

This explanatory retrospective mixed-method study consisted of a quantitative and a qualitative part. Patients from six hospitals and six different wards i.e. orthopaedics, surgery, pulmonary diseases, internal medicine, cardiology and gastroenterology were included. At these wards, MedRec was implemented both on hospital admission and discharge. The number of pharmacy interventions was collected and classified in two subcategories. First, the number of interventions to resolve unintended discrepancies (elimination of differences between listed medication and the patient’s actual medication use). And second, the number of medication optimizations (optimization of pharmacotherapy e.g. eliminating double medication). Based on these quantitative results and interviews, a focus group was performed to give insight in local MedRec processes to address differences in context between hospitals. Descriptive analysis (quantitative) and content analysis (qualitative) was used.

Results

On admission 765 (85%) patients from six hospitals, received MedRec by trained nurses, pharmacy technicians, pharmaceutical consultants or pharmacists. Of those, 36–95% (mean per patient 2.2 (SD ± 2.4)) had at least one discrepancy. Upon discharge, these numbers were among 632 (70%) of patients, 5–28% (mean per patient 0.7 (SD 1.2)). Optimizations in pharmacotherapy were implemented for 2% (0.4–3.7 interventions per patient upon admission) to 95% (0.1–1.7 interventions per patient upon discharge) of patients. The main themes explaining differences in numbers of interventions were patient-mix, the type of healthcare professionals involved, where and when patient interviews for MedRec were performed and finally, embedding and extent of medication optimization.

Conclusions

Hospitals differed greatly in the number of interventions performed during MedRec. Differences in execution of MedRec and local context determines the number of interventions. This study can support hospitals who want to optimize MedRec processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08118-8.

Interventions to Enhance Medication Safety in Residential Aged-care Settings: An Umbrella Review

AIM

To conduct a systematic synthesis of existing evidence reviews on interventions to enhance medication safety in residential aged-care settings (RACS) to establish and compare their effectiveness.

METHOD

This umbrella review included examination of meta-analyses, scoping and systematic reviews. Four electronic databases were examined for eligible reviews. Two authors critically appraised those meeting the inclusion criteria using the Joanna Briggs Institute Critical Appraisal Instrument.

RESULTS

Fifteen reviews covering 171 unique, primary studies were included. Of the variety of interventions identified in the literature, five main categories of interventions were commonly reported to be effective in promoting medication safety in RACS (medication review, staff education, multidisciplinary team meetings, computerised clinical decision support systems and miscellaneous). Most reviews showed mixed evidence to support intervention effectiveness due to the significant heterogeneity between studies in their sites, sample sizes and intervention periods. In all intervention categories, pharmacists' collaboration was most beneficial, showing definitive evidence for improving medication safety and quality of prescribing in RACS. Eight reviews recommended multicomponent interventions, particularly medication reviews and staff education, but specific details were infrequently provided. Only five reviews presented insights into implementation facilitators and barriers, while the sustainability of interventions was only discussed in one review.

CONCLUSION

There is strong evidence to support the four main categories of interventions identified. However, limited details are available regarding the most appropriate design and implementation of multicomponent interventions and the sustainability of all interventions, thus solid recommendations cannot be made. Future research in this field should focus on producing theoretically informed, methodologically robust, original research, particularly regarding the design, implementation and sustainability of multicomponent interventions, which appears the most promising approach.

Benefits of medication charts provided at transitions of care: a narrative systematic review

OBJECTIVES

Particularly at transitions of care points information concerning current medication tends to be incomplete. A medication chart that contains all essential information on current therapy is likely to be a helpful tool for patients and healthcare providers. We aimed to investigate any type of benefits associated with medication charts provided at transition points.

METHODS

A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. Two databases, two online journals and two association websites dedicated to biomedicine and pharmacy issues were consulted to identify studies for the review using the search term 'medication chart' and synonyms. We run our search from database inception up to March 2019. Studies of any study design, intervention and population which examined the effect of paper-based medication charts were included. We extracted study results narratively and coded and classified them by themes and categories inductively by using the 'framework method' with content analysis. The methodological quality of the studies was assessed using the Effective Public Health Practice Project (EPHPP) tool.

RESULTS

From the 846 retrieved articles, 30 studies met the inclusion criteria, mostly from Germany (18 studies) and the USA (5 studies). Thirteen studies reported a statistically significant result. In the 'patient theme', the most obvious benefits were an increase in medication knowledge, a reduction of medication errors and higher medication adherence. In the 'interdisciplinary theme', a medication chart represented a helpful tool to increase communication and inter-sectoral cooperation between healthcare providers. In the 'theme of terms and conditions', accuracy and currency of data are prerequisites for any positive effect. The quality of the studies was classified predominantly weak mainly due to unmet good quality criteria (no randomised controlled trials study design, no reported dropouts).

CONCLUSION

Overall, the reviewed studies suggested some benefits when using medication charts. Healthcare providers could consider using medication charts in their counselling practice. However, it is unknown whether the reported benefits lead to measurable improvement in clinical outcomes. PROSPERO REGISTRATION NUMBER.

Prescribing errors by junior doctors- A comparison of errors with high risk medicines and non-high risk medicines

INTRODUCTION

Prescribing errors in hospital are common. However, errors with high-risk-medicines (HRMs) have a greater propensity to cause harm compared to non-HRMs. We do not know if there are differences between the causes of errors with HRMs and non-HRMs but such knowledge might be useful in developing interventions to reduce errors and avoidable harm. Therefore, this study aims to compare and contrast junior doctors' prescribing errors with HRMs to non-HRMs to establish any differences.

METHODS

A secondary analysis of fifty-nine interviews with foundation year doctors, obtained from three studies, was conducted. Using a Framework Analysis approach, through NVivo software, a detailed comparison was conducted between the unsafe acts, error-causing-conditions (ECCs), latent conditions, and types of errors related to prescribing errors with HRMs and non-HRMs.

RESULTS

In relation to unsafe acts, violations were described in the data with non-HRMs only. Differences in ECCs of HRMs and non-HRMs were identified and related to the complexity of prescribing HRMs, especially dosage calculations. There were also differences in the circumstances of communication failures: with HRMs ineffective communication arose with exchanges with individuals outside the immediate medical team while with non-HRMs these failures occurred with exchanges within that team. Differences were identified with the latent conditions: with non-HRMs there was a reluctance to seek seniors help and with HRMs latent conditions related to the organisational system such as the inclusion of trade names in hospital formularies. Moreover, prescribing during the on-call period was particularly challenging especially with HRMs.

CONCLUSION

From this secondary analysis, differences in the nature and type of prescribing errors with HRMs and non-HRMs were identified, although further research is needed to investigate their prevalence. As errors with HRMs have the potential to cause great harm it may be appropriate to target limited resources towards interventions that tackle the underlying causes of such errors. Equally concerning, however, was the sense that doctors regard the prescribing of non-HRMs as 'safe'.

Reducing adverse medication events in mental health: Australian National Survey

AIM

To determine the extent to which evidence-based medication safety practices have been implemented in public and private mental health inpatient units across Australia.

METHODS

The Reducing Adverse Medication Events in Mental Health survey was piloted in Victoria, Australia, in 2015, and rolled out nationally in 2016. In total, 235 mental health inpatient units from all States and Territories in Australia were invited to participate. The survey included questions about the demographics of the mental health unit, evidence-based strategies to improve prescription writing, the administration and dispensing of medicines and pharmacy-led interventions, and also questions relating to consumer engagement in medication management and shared decision-making.

RESULTS

The response rate was 45% (N = 106 units). Overall, the survey found that 57% of the mental health units had fully or partially implemented evidence-based medication safety practices. High levels of implementation (80%) were reported for the use of standardized medication charts such as the National Inpatient Medication Chart as a way to improve medication prescription writing. Most (71%) of the units were using standardized forms for recording medication histories, and 56% were using designated forms for Medication Management Plans. However, less than one-fifth of the units had implemented electronic medication management systems, and the majority of units still relied on paper-based documentation systems.Interventions to improve medicine administration and dispensing were not highly utilized. Individual patient-based medication distribution systems were fully implemented in only 9% of the units, with a high reliance (81%) on ward stock or imprest systems. Tall Man lettering for labelling was implemented in only one-third of the units.Pharmacy services were well represented in mental health units, with 80% having access to onsite pharmacist services providing assessments of current medications and clinical review services, adverse drug reaction reporting and management services, patient and carer education and counselling, and medicines information services. However, pharmacists were involved in only half of medical reconciliations. Their involvement in post-discharge follow-up was limited to 4% of units.

CONCLUSIONS

Gaps in medication safety practices included limited use of individual patient supply systems for medication distribution, a high reliance on ward stock systems and high reliance on paper-based systems for medication prescribing and administration. With regards to service provision, clinical pharmacist involvement in medical reconciliation services, therapeutic drug monitoring and interdisciplinary ward rounds should be increased. Discharge and post-discharge services were major gaps in service provision.

Comparison of medication policies to guide nursing practice across seven Victorian health services

Objectives The objective of this paper is to review and compare the content of medication management policies across seven Australian health services located in the state of Victoria. Methods The medication management policies for health professionals involved in administering medications were obtained from seven health services under one jurisdiction. Analysis focused on policy content, including the health service requirements and regulations governing practice. Results and Conclusions The policies of the seven health services contained standard information about staff authorisation, controlled medications and poisons, labelling injections and infusions, patient self-administration, documentation and managing medication errors. However, policy related to individual health professional responsibilities, single- and double-checking medications, telephone orders and expected staff competencies varied across the seven health services. Some inconsistencies in health professionals' responsibilities among medication management policies were identified. What is known about the topic? Medication errors are recognised as the single most preventable cause of patient harm in hospitals and occur most frequently during administration. Medication management is a complex process involving several management and treatment decisions. Policies are developed to assist health professionals to safely manage medications and standardise practice; however, co-occurring activities and interruptions increase the risk of medication errors. What does this paper add? In the present policy analysis, we identified some variation in the content of medication management policies across seven Victorian health services. Policies varied in relation to medications that require single- and double-checking, as well as by whom, nurse-initiated medications, administration rights, telephone orders and competencies required to check medications. What are the implications for practitioners? Variation in medication management policies across organisations is highlighted and raises concerns regarding consistency in governance and practice related to medication management. Lack of practice standardisation has previously been implicated in medication errors. Lack of intrajurisdictional concordance should be addressed to increase consistency. Inconsistency in expectations between healthcare services may lead to confusion about expectations among health professionals moving from one healthcare service to another, and possibly lead to increased risk of medication errors.

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.

Methods to reduce prescribing errors in elderly patients with multimorbidity

The global population of multimorbid older people is growing steadily. Multimorbidity is the principal cause of complex polypharmacy, which in turn is the prime risk factor for inappropriate prescribing and adverse drug reactions and events. Those who prescribe for older frailer multimorbid people are particularly prone to committing prescribing errors of various kinds. The causes of prescribing errors in this patient population are multifaceted and complex, including prescribers' lack of knowledge of aging physiology, geriatric medicine, and geriatric pharmacotherapy, overprescribing that frequently leads to major polypharmacy, inappropriate prescribing, and inappropriate drug omission. This review examines the various ways of minimizing prescribing errors in multimorbid older people. The role of education in physician prescribers and clinical pharmacists, the use of implicit and explicit prescribing criteria designed to improve medication appropriateness in older people, and the application of information and communication-technology systems to minimize errors are discussed in detail. Although evidence to support any single intervention to prevent prescribing errors in multimorbid elderly people is inconclusive or lacking, published data support focused prescriber education in geriatric pharmacotherapy, routine application of STOPP/START (screening tool of older people's prescriptions/screening tool to alert to right treatment) criteria for potentially inappropriate prescribing, electronic prescribing, and close liaison between clinical pharmacists and physicians in relation to structured medication review and reconciliation. Carrying out a structured medication review aimed at optimizing pharmacotherapy in this vulnerable patient population presents a major challenge. Another challenge is to design, build, validate, and test by clinical trials suitably versatile and efficient software engines that can reliably and swiftly perform complex medication reviews in older multimorbid people. The European Union-funded SENATOR and OPERAM clinical trials commencing in 2016 will examine the impact of customized software engines in reducing medication-related morbidity, avoidable excess cost, and rehospitalization in older multimorbid people.

Prescription errors in the National Health Services, time to change practice

INTRODUCTION

Medication error is a major source of iatrogenic illness. Error in prescription is the most common form of avoidable medication error. We present our study, performed at two, UK, National Health Services Hospitals.

MATERIAL AND METHODS

The prescription practice of junior doctor's working on general medical and surgical wards in National Health Service District General and University Teaching Hospitals in the UK was reviewed. Practice was assessed against standard hospital prescription charts, developed in accordance with local pharmacy guidance.

RESULTS

A total of 407 prescription charts were reviewed in both initial audit and re-audit one year later. In the District General Hospital, documentation of allergy, weight and capital-letter prescription was achieved in 31, 5 and 40% of charts, respectively. Forty-nine per cent of discontinued prescriptions were properly deleted and signed for. In re-audit significant improvement was noted in documentation of the patient's name 100%, gender 54%, allergy status 51% and use of generic drug name 71%. Similarly, in the University Teaching Hospital, 82, 63 and 65% compliance was achieved in documentation of age, generic drug name prescription and capital-letter prescription, respectively. Prescription practice was reassessed one year later after recommendations and changes in the prescription practice, leading to significant improvement in documentation of unit number, generic drug name prescription, insulin prescription and documentation of the patient's ward.

CONCLUSION

Prescription error remains an important, modifiable form of medical error, which may be rectified by introducing multidisciplinary assessment of practice, nationwide standardised prescription charts and revision of current prescribing clinical training.

A comparison of educational interventions to improve prescribing by junior doctors

BACKGROUND

Prescribing is a complex task with potential for many types of error to occur. Despite the introduction of a standard national medication chart for Australian hospital inpatients in 2006, simple prescribing errors are common.

AIM

To compare the effect of quality improvement initiatives on the rate of simple prescribing errors.

DESIGN

A prospective, multisite comparison of prescribing education interventions.

METHODS

Using three hospital sites, we compared site-specific changes in prescribing error rates following use of an online education module alone (low intensity) with prescribing error rates following a high-intensity intervention (comprising the same online education module plus nurse education and academic detailing of junior prescribers). The study period was 4 months between May and August 2011.

RESULTS

Full completion of the adverse drug reactions field did not improve after either intervention; however, there was better documentation of some elements following high-intensity intervention. Prescriber performance improved significantly for more elements in the regular prescription category than any other category of prescription. Legibility of medication name improved across all categories following interventions. Clarity of frequency, prescriber name and documentation of indication improved following both high- and low-intensity intervention.

CONCLUSIONS

Improvements were seen in several prescription elements after the intervention but the majority of elements that improved were affected by both low- and high-intensity interventions. Despite targeted intervention, significant rates of prescribing breaches persisted. The prevalence of prescription breaches partially responds to an online education module. The nature of any additional intervention that would be effective is unclear.

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

OBJECTIVES

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

DESIGN

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

SETTING

A London teaching hospital.

INTERVENTIONS/METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of the Delphi technique to determine safety features to be included in a neonatal and paediatric prescription chart

BACKGROUND

Neonatal and paediatric patients are especially vulnerable to serious injury as a result of medication errors due to their small size, physiological immaturity and limited compensatory abilities. The prescription chart remains an essential form of communication of prescribing decisions and instructions. Modifications to the safety features of prescription charts have been shown to reduce the frequency of medication errors.

OBJECTIVE

To determine, using the Delphi technique, which safety features should be included in the inpatient neonatal and paediatric prescription chart to help minimise the risk of medication errors associated with the use of the chart.

SETTING

Acute general hospital in Malta.

METHOD

A two-round modified e-Delphi process was conducted. The Delphi questionnaire was developed from a mapping process, a literature search and references supporting the literature review. It comprised 155 safety features for consensus. The Delphi panel consisted of nine doctors, five nurses and four pharmacists. Participants were asked to rate their agreement to the inclusion of these features in the local chart using a three-point Likert scale, and to add further comments as necessary at the end of each section. In the second round, participants were given the opportunity to change their individual response in view of the groups' response.

MAIN OUTCOME MEASURE

This was set at a 70% level of agreement.

RESULTS

Results from each round were analysed to provide the percentage frequencies and number of participants who chose each point from the Likert scale provided, and the response count for each safety feature. A ≥70% consensus level was achieved on: 115 safety features in Round 1 (total: 155 safety features) and 23 safety features in Round 2 (total: 40 safety features) while only 17 safety features did not achieve consensus at the end of the process.

CONCLUSION

Consensus was achieved on 133 safety features to be included in the neonatal and paediatric prescription chart. Five safety features achieved consensus disagreement for their inclusion in the chart. Identifying the appropriate safety features forms part of an essential strategy to reduce the incidence of medication errors associated with the use of the chart in these patients.

Standards of prescription writing in a long-term psychogeriatric unit: a series of clinical audits

Objective

The aim of this study was to improve the quality of prescription writing in a long-term psychogeriatric inpatient unit by a combination of serial audits and interventions designed to address the identified deficiencies.

Methods

We undertook three clinical audits of the prescription sheets used in an inpatient unit providing continuing care for residents with severe and enduring mental illness and dementia. Based on the findings of the first audit a set of prescribing guidelines was implemented into the ward. Following the second audit a new prescription sheet was developed. The format of the new prescription sheet was designed to account for the needs of the unit and to adhere to Irish and UK best practise guidelines. Two months after its introduction we undertook a third audit.

Results

Completion of the drug sensitivity box increased from 25% at audit one to 100% at audit three. Other specific aspects of prescription writing that had been poor at the beginning of the audit cycle also showed improvement: prescribing of generic psychotropic drugs increased by 69% and inclusion of the prescribers Medical Council Registration Number increased by 78%. However, some basic aspects of prescription writing remained weak such as frequency of drug administration and documentation of the stop/review date for ‘as required’ medication.

Conclusion

The results of this study suggest that clinical audit and feedback can improve the quality of prescriptions in an in-patient setting.

Initiatives promoting seamless care in medication management: an international review of the grey literature

BACKGROUND

Patients' transition between hospital and community is a high-risk period for the occurrence of medication-related problems.

AIM OF THE REVIEW

The objective was to review initiatives, implemented at national and regional levels in seven selected countries, aiming at improving continuity in medication management upon admission and hospital discharge.

METHOD

We performed a structured search of grey literature, mainly through relevant websites (scientific, professional and governmental organizations). Regional or national initiatives were selected. For each initiative data on the characteristics, impact, success factors and barriers were extracted. National experts were asked to validate the initiatives identified and the data extracted.

RESULTS

Most initiatives have been implemented since the early 2000 and are still ongoing. The principal actions include: development and implementation of guidelines for healthcare professionals, national information campaigns, education of healthcare professionals and development of information technologies to share data across settings of care. Positive results have been partially reported in terms of intake into practice or process measures. Critical success factors identified included: leadership and commitment to convey national and local forces, tailoring to local settings, development of a regulatory framework and information technology support. Barriers identified included: lack of human and financial resources, questions relative to responsibility and accountability, lack of training and lack of agreement on privacy issues.

CONCLUSION

Although not all initiatives are applicable as such to a particular healthcare setting, most of them convey very interesting data that should be used when drawing recommendations and implementing approaches to optimize continuity of care.

Capture and documentation of coded data on adverse drug reactions: an overview

Allergic responses to prescription drugs are largely preventable, and incur significant cost to the community both financially and in terms of healthcare outcomes. The capacity to minimise the effects of repeated events rests predominantly with the reliability of allergy documentation in medical records and computerised physician order entry systems (CPOES) with decision support such as allergy alerts. This paper presents an overview of the nature and extent of adverse drug reactions (ADRs) in Australia and other developed countries, a discussion and evaluation of strategies which have been devised to address this issue, and a commentary on the role of coded data in informing this patient safety issue. It is not concerned with pharmacovigilance systems that monitor ADRs on a global scale. There are conflicting reports regarding the efficacy of these strategies. Although in many cases allergy alerts are effective, lack of sensitivity and contextual relevance can often induce doctors to override alerts. Human factors such as user fatigue and inadequate adverse drug event reporting, including ADRs, are commonplace. The quality of and response to allergy documentation can be enhanced by the participation of nurses and pharmacists, particularly in medication reconciliation. The International Classification of Diseases (ICD) coding of drug allergies potentially yields valuable evidence, but the quality of local and national level coded data is hampered by under-documenting and under-coding.

Improving the quality of prescribing in the emergency department

Prescribing errors are common and can have a significant negative impact on patients. This article presents an audit and intervention which aimed to improve prescribing safety, documentation and handover in the emergency department. The authors identified shortcomings in the emergency department drug chart, which were subsequently confirmed by audit. To address these shortcomings, a new drug chart was designed and introduced, before repeating the audit. This intervention resulted in significantly more frequent documentation of key aspects of the prescription including date and time, and rate and volume for infusions. This low cost intervention is applicable to other emergency department settings.

The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over study

PURPOSE OF STUDY

Initiatives to standardise hospital paper-based prescription charts are underway in various countries in an effort to reduce prescribing errors. The aim of this study was to investigate the extent to which prescribing error rates are influenced by prescription chart design and familiarity.

STUDY DESIGN

In this prospective, randomised, cross-over study, Foundation Year 1 doctors working in five Scottish National Health Service (NHS) Boards participated in study sessions during which they were asked to prescribe lists of medications for five fictional patients using a different design of paper prescription chart for each patient. Each doctor was timed completing each set of prescriptions, and each chart was subsequently assessed against a predefined list of possible errors. A mixed modelling approach using three levels of variables (design of and familiarity with a chart, prescribing speed and individual prescriber) was employed.

RESULTS

A total of 72 Foundation Year 1 doctors participated in 10 data-collection sessions. Differences in prescription chart design were associated with significant variations in the rates of prescribing error. The charts from NHS Highland and NHS Grampian produced significantly higher error rates than the other three charts. Participants who took longer to complete their prescriptions made significantly fewer errors, but familiarity with a chart did not predict error rate.

CONCLUSIONS

This study has important implications for prescription chart design and prescribing education. The inverse relationship between the time taken to complete a prescribing task and the rate of error emphasises the importance of attention to detail and workload as factors in error causation. Further work is required to identify the characteristics of prescription charts that are protective against errors.

Balanced prescribing - principles and challenges

Balanced prescribing is a process that recommends a medicine appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, a dosage regimen that optimizes the balance of benefit to harm. The essential steps in achieving this are (a) careful attention to the history, examination, and investigation of the patient's condition and drug therapy, (b) accurate diagnosis, (c) detailed attention to prescribing the dosage regimen in the light of the therapeutic goal, (d) careful writing of the prescription and (e) regular monitoring of therapy, including attention to beneficial outcomes, adverse reactions, and patient adherence. The two major requirements in determining the dosage regimen are (1) understanding the pathophysiology of a health problem and matching it to the mechanisms of action of the relevant medicines and (2) assessing the benefit to harm balance of the therapy, although the difficulties in doing this in the individual are great. Major challenges in prescribing include provision of adequate education for all prescribers early in their undergraduate training and maintaining their expertise after graduation, obtaining evidence to inform appropriate monitoring of therapy, reducing the incidence of medication errors, and providing high quality information that will at the same time guide prescribing decisions and be sufficiently flexible to allow prescribers to tailor therapy to the needs of the individual patient. Careful attention to all facets of prescribing can improve the chances of benefit, reduce the risks of adverse reactions and interactions, and enhance adherence to therapy.

An evaluation framework for non-medical prescribing research

Without robust and credible evidence for the benefits in health outcomes of non-medical prescribing, widespread implementation will be challenging. Our aim is to develop a consistent evaluation framework that could be applied to non-medical prescribing research. An informal collaboration was initiated in 2008 by a group of pharmacists from Australia and New Zealand to assist in information sharing, pilot design, methodologies and evaluation for pharmacist prescribing. Different pilots used different models, methodologies and evaluation. It was agreed that the development of a consistent evaluation framework to be applied to future research on non-medical prescribing was required. The framework would help to align the outcomes of different research pilots and enable the comparison of endpoints to determine the effectiveness of a non-medical prescribing intervention.

Recurrent Laryngeal Nerve Monitoring during Thyroid Surgery

Objective

Injury to the recurrent laryngeal nerve (RLN) remains a significant cause of morbidity during thyroid surgery. Intraoperative nerve monitoring (IONM) is being applied in many centers to facilitate nerve identification. The aim of this study was to elucidate normative human vagal and recurrent laryngeal nerve electromyograhic (EMG) parameters during standard IONM application.

Study Design

A prospective IONM study conducted over an 8-month period. Internal review board (IRB) approval was obtained.

Settings

Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear Infirmary, Boston.

Subjects and Methods

All patients who were scheduled for routine thyroid, parathyroid, or neck exploration surgery were invited to participate. All patients had a preoperative and postoperative laryngeal examination to assess vocal cord function. Any patient with an abnormal preoperative laryngeal examination was excluded.

Results

Fifty-eight patients participated in this study. The right and left RLN latencies were similar. The left vagus latency was greater than the right vagus but was not significant. The RLN latency was significantly less than the vagus nerve. The right vagus nerve amplitude was significantly greater than the left. There was no difference between male and female amplitudes for either the RLN or vagus nerve.

Conclusion

This study highlights the electrophysiological/EMG differences and similarities between the RLN and vagus nerve. Normative amplitude measurements for bilateral RLN and vagus nerve stimulation are presented. There are limited data available in the literature on normal RLN and vagal EMG signals generated during thyroid surgery.

Pilot of a National Inpatient Medication Chart in Australia: improving prescribing safety and enabling prescribing training

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Prescribing errors are common and are caused by multiple factors. Standard medication charts have been recommended by British and Australian Health services. A study of a standard medication chart in five hospitals in one state of Australia significantly reduced prescribing errors.

WHAT THIS STUDY ADDS

A standard medication chart developed in one area can be adopted through a collaborative process and successfully implemented across a diverse country resulting in similar reductions in prescribing errors. Three of the four stages of the prescribing process (information gathering, decision making and communication of instructions) can be improved by the use of an improved standard medication chart. The introduction of a standard medication chart has enabled development of standard prescribing education programmes.

AIMS

To establish whether a standard national inpatient medication chart (NIMC) could be implemented across a range of sites in Australia and reduce frequency of prescribing errors and improve the completion of adverse drug reaction (ADR) and warfarin documentation.

METHODS

A medication chart, which had previously been implemented in one state, was piloted in 22 public hospitals across Australia. Prospective before and after observational audits of prescribing errors were undertaken by trained nurse and pharmacist teams. The introduction of the chart was accompanied by local education of prescribers and presentation of baseline audit findings. RESULTS After the introduction of the NIMC, prescribing errors decreased by almost one-third, from 6383 errors in 15,557 orders, a median (range) of 3 (0-48) per patient to 4293 in 15,416 orders, 2 (0-45) per patient (Wilcoxon Rank Sum test, P < 0.001). The documentation of drugs causing previous ADRs increased significantly from 81.9% to 88.9% of drugs (χ(2) test, P < 0.001). The documentation of the indication for warfarin increased from 12.1 to 34.3% (χ(2) test, P= 0.001) and the documentation of target INR increased from 10.8 to 70.0% (χ(2) test, P < 0.001) after implementation of the chart.

CONCLUSIONS

National implementation of a standard medication chart is possible. Similar reduction in the rate of prescribing errors can be achieved in multiple sites across one country. The consequent benefits for patient care and training of staff could be significant.

Improving Medication Reconciliation on the Surgical Wards of a District General Hospital

During a routine audit it was noted that the surgical wards were consistently underperforming in their rate of medicines reconciliation in comparison to other specialities. The process of medication reconciliation is usually performed by junior doctors during the admission process and can be a complex task which is usually undertaken in the midst of several other jobs. The aim of this project was to review this process and identify methods of improving patient safety. This led to the design of a surgical admissions proforma which incorporated a 'medications on admission' section, to be used for reconciliation. Over a six month period from its introduction into a pilot ward it was noted to improve medication reconciliation from 60% to 85%. The benefits were discussed with members of the trust and a standardised version of the admissions proforma has since been rolled out to all hospitals within the trust.

Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study

BACKGROUND

Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries. Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use. This study evaluated the effectiveness of two commercial e-prescribing systems in reducing prescribing error rates and their propensities for introducing new types of error.

METHODS AND RESULTS

We conducted a before and after study involving medication chart audit of 3,291 admissions (1,923 at baseline and 1,368 post e-prescribing system) at two Australian teaching hospitals. In Hospital A, the Cerner Millennium e-prescribing system was implemented on one ward, and three wards, which did not receive the e-prescribing system, acted as controls. In Hospital B, the iSoft MedChart system was implemented on two wards and we compared before and after error rates. Procedural (e.g., unclear and incomplete prescribing orders) and clinical (e.g., wrong dose, wrong drug) errors were identified. Prescribing error rates per admission and per 100 patient days; rates of serious errors (5-point severity scale, those ≥3 were categorised as serious) by hospital and study period; and rates and categories of postintervention "system-related" errors (where system functionality or design contributed to the error) were calculated. Use of an e-prescribing system was associated with a statistically significant reduction in error rates in all three intervention wards (respectively reductions of 66.1% [95% CI 53.9%-78.3%]; 57.5% [33.8%-81.2%]; and 60.5% [48.5%-72.4%]). The use of the system resulted in a decline in errors at Hospital A from 6.25 per admission (95% CI 5.23-7.28) to 2.12 (95% CI 1.71-2.54; p<0.0001) and at Hospital B from 3.62 (95% CI 3.30-3.93) to 1.46 (95% CI 1.20-1.73; p<0.0001). This decrease was driven by a large reduction in unclear, illegal, and incomplete orders. The Hospital A control wards experienced no significant change (respectively -12.8% [95% CI -41.1% to 15.5%]; -11.3% [-40.1% to 17.5%]; -20.1% [-52.2% to 12.4%]). There was limited change in clinical error rates, but serious errors decreased by 44% (0.25 per admission to 0.14; p = 0.0002) across the intervention wards compared to the control wards (17% reduction; 0.30-0.25; p = 0.40). Both hospitals experienced system-related errors (0.73 and 0.51 per admission), which accounted for 35% of postsystem errors in the intervention wards; each system was associated with different types of system-related errors.

CONCLUSIONS

Implementation of these commercial e-prescribing systems resulted in statistically significant reductions in prescribing error rates. Reductions in clinical errors were limited in the absence of substantial decision support, but a statistically significant decline in serious errors was observed. System-related errors require close attention as they are frequent, but are potentially remediable by system redesign and user training. Limitations included a lack of control wards at Hospital B and an inability to randomize wards to the intervention.

Color-coding and human factors engineering to improve patient safety characteristics of paper-based emergency department clinical documentation

OBJECTIVE

Investigators studied an emergency department (ED) physical chart system and identified inconsistent, small font labeling; a single-color scheme; and an absence of human factors engineering (HFE) cues. A case study and description of the methodology with which surrogate measures of chart-related patient safety were studied and subsequently used to reduce latent hazards are presented.

BACKGROUND

Medical records present a challenge to patient safety in EDs. Application of HFE can improve specific aspects of existing medical chart organization systems as they pertain to patient safety in acute care environments.

METHODS

During 10 random audits over 5 consecutive days (573 data points), 56 (9.8%) chart binders (range 0.0-23%) were found to be either misplaced or improperly positioned relative to other chart binders; 12 (21%) were in the critical care area. HFE principles were applied to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues.

RESULTS

Post-intervention audits revealed significant reductions in chart binder location problems overall (p < 0.01), for Urgent Care A and B pods (6.4% to 1.2%; p < 0.05), Fast Track C pod (19.3% to 0.0%; p < 0.05) and Behavioral/Substance Abuse D pod (15.7% to 0.0%; p < 0.05) areas of the ED. The critical care room area did not display an improvement (11.4% to 13.2%; p = 0.40).

CONCLUSIONS

Application of HFE methods may aid the development, assessment, and modification of acute care clinical environments through evidence-based design methodologies and contribute to safe patient care delivery.