Bryony Dean

Causes of prescribing errors in hospital inpatients: a prospective study

BACKGROUND To prevent errors made during the prescription of drugs, we need to know why they arise. Theories of human error used to understand the causes of mistakes made in high-risk industries are being used in health-care. They have not, however, been applied to prescribing errors, which are a great cause of patient harm. Our aim was to use this approach to investigate the causes of such errors. METHODS Pharmacists at a UK teaching hospital prospectively identified 88 potentially serious prescribing errors. We interviewed the prescribers who made 44 of these, and analysed our findings with human error theory. FINDINGS Our results suggest that most mistakes were made because of slips in attention, or because prescribers did not apply relevant rules. Doctors identified many risk factors-work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. Organisational factors were also identified, and included inadequate training, low perceived importance of prescribing, a hierarchical medical team, and an absence of self-awareness of errors. INTERPRETATION To reduce prescribing errors, hospitals should train junior doctors in the principles of drug dosing before they start prescribing, and enforce good practice in documentation. They should also create a culture in which prescription writing is seen as important, and formally review interventions made by pharmacists, locum arrangements, and the workload of junior doctors, and make doctors aware of situations in which they are likely to commit errors.

Prescribing errors in hospital inpatients: their incidence and clinical significance

Background: It has been estimated that 1–2% of US inpatients are harmed by medication errors, the majority of which are errors in prescribing. The UK Department of Health has recommended that serious errors in the use of prescribed drugs should be reduced by 40% by 2005; however, little is known about the current incidence of prescribing errors in the UK. This pilot study sought to investigate their incidence in one UK hospital. Methods: Pharmacists prospectively recorded details of all prescribing errors identified in non-obstetric inpatients during a 4 week period. The number of medication orders written was estimated from a 1 in 5 sample of inpatients. Potential clinical significance was assessed by a pharmacist and a clinical pharmacologist. Results: About 36 200 medication orders were written during the study period, and a prescribing error was identified in 1.5% (95% confidence interval (CI) 1.4 to 1.6). A potentially serious error occurred in 0.4% (95% CI 0.3 to 0.5). Most of the errors (54%) were associated with choice of dose. Error rates were significantly different for different stages of patient stay (p<0.0001) with a higher error rate for medication orders written during the inpatient stay than for those written on admission or discharge. While the majority of all errors (61%) originated in medication order writing, most serious errors (58%) originated in the prescribing decision. Conclusions: There were about 135 prescribing errors identified each week, of which 34 were potentially serious. Knowing where and when errors are most likely to occur will be helpful in designing initiatives to reduce them. The methods developed could be used to evaluate such initiatives.

When do medication administration errors happen to hospital inpatients

The aim of this study was to determine when medication administration errors (MAEs) are most likely to occur. MAEs were identified by observing nurses preparing and administering medication on a care of the elderly ward during two eight‐day periods. The exposure of individual patients to MAEs was also determined.

The use of serial point-prevalence studies to investigate hospital anti-infective prescribing

Objectives — To develop and test an efficient, reproducible method for the surveillance of hospital anti‐infective use; to use this method to investigate patterns of anti‐infective prescribing.

When should pharmacists visit their wards? An application of simulation to planning hospital pharmacy services.

This paper reports a pilot study of the use of simulation in planning hospital pharmacy services. The objectives were to create a simulation model of the hospital drug distribution system, to use the model to investigate a simple problem and to assess the potential for simulation to aid decision making in hospital pharmacy management. The problem chosen for investigation focused on the UK ward pharmacy system, where a pharmacist visits each ward daily to initiate the supply of newly prescribed non‐stock medication. A simulation model was used to investigate how changing the time of the ward pharmacists visit could affect the mean time delay between the prescription of a non‐stock drug and the arrival of that drug on the ward. The simulation results suggest that the time of day at which pharmacists visit their wards can have a major impact on delay times, and that the relative benefit of different visit times is likely to vary between wards. Simulation was found to be a useful approach to investigating different service alternatives without the expense and disruption of assessing each in practice.

Measuring the impact of medicines information services on patient care: methodological considerations.

Introduction: Medicines information services (MISs) aim to promote the safe, effective and economic use of medicines. Results from published studies suggest that they provide effective information, which in many cases results in improved patient outcome. However, there are several methodological issues that are important in the interpretation of such studies.Aim: To address methodological issues in the evaluation of MISsObjectives: To carry out a critical appraisal of papers assessing the impact on patient outcome of passive information given to health care professionals, to identify the key methodological issues and to make recommendations for future research in Europe. Methods: Literature search to identify relevant papers meeting the inclusion criteria, critical evaluation of the methods usedResults: Most studies have been conducted in the United States. Various methodological considerations were identified: study design, sampling, data collection, choice of outcome measures, and validity. The results of each study are interpreted in view of the methods used. In addition, the implications of the methods selected on the validity, reliability and generalisability of the results are discussed. Finally, suggestions for future studies are provided, in order to maximise validity and reliability.

An evaluation of the process‐related medication risks for elective surgery patients from pre‐operative assessment to discharge

Aim — To investigate where the process‐related medication risks occur in an elective surgery service with a pre‐operative assessment clinic (PAC) and make recommendations for how pharmacy services should best be provided.

The validation of an existing method of scoring the severity of medication administration errors for use in Germany

Objective: The aim of this study was to assess the validity and reliability of an existing method of scoring the severity of medication administration errors, developed in the United Kingdom (UK), for use in Germany.Method: 10 doctors, 10 nurses, and 10 pharmacists from German hospitals were asked to score the potential clinical significance of 49 cases of medication administration errors on a visual analogue scale. Main outcome measure: Generalisability theory was used to determine the minimum number of judges required to obtain a reliable mean score. Validity was assessed by comparing the mean scores given by the judges to the known outcome of the errors for a subset of the cases. German results were compared to original UK data.Results: The scores of 27 judges could be used (nine from each profession). At least three health professionals, one from each profession, were required to achieve a generalisability coefficient of 0.86, indicating acceptable reliability. The mean scores were found to be valid indicators of the potential severity of the errors. German scores were significantly below UK scores for the same cases. Conclusion: The mean score calculated from scores given by one doctor, one nurse and one pharmacist from the population of German health professionals was a valid and reliable measure of the potential clinical significance of medication administration errors. That German health professionals see cases as less dangerous than their UK counterparts is worthy of further investigation.