D. Stowasser

Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis

Objective To synthesise qualitative studies that explore prescribers’ perceived barriers and enablers to minimising potentially inappropriate medications (PIMs) chronically prescribed in adults. Design A qualitative systematic review was undertaken by searching PubMed, EMBASE, Scopus, PsycINFO, CINAHL and INFORMIT from inception to March 2014, combined with an extensive manual search of reference lists and related citations. A quality checklist was used to assess the transparency of the reporting of included studies and the potential for bias. Thematic synthesis identified common subthemes and descriptive themes across studies from which an analytical construct was developed. Study characteristics were examined to explain differences in findings. Setting All healthcare settings. Participants Medical and non-medical prescribers of medicines to adults. Outcomes Prescribers’ perspectives on factors which shape their behaviour towards continuing or discontinuing PIMs in adults. Results 21 studies were included; most explored primary care physicians’ perspectives on managing older, community-based adults. Barriers and enablers to minimising PIMs emerged within four analytical themes: problem awareness; inertia secondary to lower perceived value proposition for ceasing versus continuing PIMs; self-efficacy in regard to personal ability to alter prescribing; and feasibility of altering prescribing in routine care environments given external constraints. The first three themes are intrinsic to the prescriber (eg, beliefs, attitudes, knowledge, skills, behaviour) and the fourth is extrinsic (eg, patient, work setting, health system and cultural factors). The PIMs examined and practice setting influenced the themes reported. Conclusions A multitude of highly interdependent factors shape prescribers’ behaviour towards continuing or discontinuing PIMs. A full understanding of prescriber barriers and enablers to changing prescribing behaviour is critical to the development of targeted interventions aimed at deprescribing PIMs and reducing the risk of iatrogenic harm.

A randomised controlled trial of medication liaison services - patient outcomes

Objectives: To evaluate the effects of a Medication Liaison Service (MLS) on quality of medication‐related information associated with hospital admission, risk of drug misadventure and other patient outcomes, and health resource utilisation.

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

Objectives: (1) To develop and implement a standard medication chart, for recording prescribing (medication orders) and administration of medication in public hospitals in Queensland. (2) To assess the chart’s impact on the frequency and type of prescribing errors, adverse drug reaction (ADR) documentation and safety of warfarin prescribing. (3) To use the chart to facilitate safe medication management training. Design, setting and participants: The medication chart was developed through a process of incident analysis and work practice mapping by a multidisciplinary collaborative. Observational audits by nurse and pharmacist pairs, of all available prescriptions before and after introduction of the standard medication chart, were undertaken in five sites. Results: Similar numbers of both patients (730 pre-implementation and 751 post-implementation; orders, 9772 before and 10 352 after) were observed. The prescribing error rate decreased from 20.0% of orders per patient before to 15.8% after (Mann–Whitney U test, p = 0.03). Previous ADRs were not documented for 19.5% of 185 patients before and 11.2% of 197 patients after (χ2, p = 0.032). Prescribing errors involving selection of a drug to which a patient had had a previous ADR decreased from 11.3% of patients before to 4.6% after (χ2, p = 0.021). International normalised ratios (INRs) >5 decreased from 1.9% of 14 405 INRs in the 12 months before to 1.45% of 15 090 INRs after (χ2, p = 0.004). After minor modifications, the chart was introduced into all hospitals statewide, which enabled standardised medication training and safer rotation of staff. The chart also formed the basis for the National Inpatient Medication Chart. Conclusion: Introduction of a standard revised medication chart significantly reduced the frequency of prescribing errors, improved ADR documentation and decreased the potential risks associated with warfarin management. The standard chart has enabled uniform training in medicine management.

First do no harm: a real need to deprescribe in older patients

Inappropriate polypharmacy in older patients imposes a significant burden of decreased physical functioning, increased risk of falls, delirium and other geriatric syndromes, hospital admissions and death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed medications. Deprescribing is the process of tapering or stopping drugs, with the goal of minimising polypharmacy and improving outcomes. Barriers to deprescribing include underappreciation of the scale of polypharmacy‐related harm by both patients and prescribers; multiple incentives to overprescribe; a narrow focus on lists of potentially inappropriate medications; reluctance of prescribers and patients to discontinue medication for fear of unfavourable sequelae; and uncertainty about effectiveness of strategies to reduce polypharmacy. Ways of countering such barriers comprise reframing the issue to one of highest quality patient‐centred care; openly discussing benefit–harm trade‐offs with patients and assessing their willingness to consider deprescribing; targeting patients according to highest risk of adverse drug events; targeting drugs more likely to be non‐beneficial; accessing field‐tested discontinuation regimens for specific drugs; fostering shared education and training in deprescribing among all members of the health care team; and undertaking deprescribing over an extended time frame under the supervision of a single generalist clinician.

Safe medication practice: attitudes of medical students about to begin their intern year.

Objectives  Interns are expected to prescribe effectively and safely. This study aimed to assess medical students’ perceptions of their readiness to prescribe, associated risks and outcome if involved in an error, as well as their perceptions of available support.

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.

Safe medication practice tutorials: A practical approach to preparing prescribers

A recent symposium focused on the importance of education as the cornerstone in the improvement of the safety of prescribing. Recommendations included enhanced pharmacology and therapeutics training for medical students and junior doctors. The General Medical Council (GMC) in the UK recommends that graduate doctors have knowledge and understanding of ‘the effective Teachers should include patient safety measures Practical teaching

A randomised controlled trial of medication liaison services - acceptance and use by health professionals

Objectives: To determine the acceptance and utility of a Medication Liaison Service (MLS) by hospital and community healthcare professionals. The MLS aimed to improve the quality and transfer of medication‐related information associated with hospital admission.

The Extended Role of the Clinical Pharmacist in the Management of Heart Failure and Acute Coronary Syndromes

Aim: To discuss the evidence‐based rationale behind the use of clinical pharmacists in the Brisbane Cardiac Consortium Clinical Support Systems Project (CSSP), and detail the pharmacist‐specific interventions that have been implemented.

Identification of medication errors by nurses during a simulated ward, medication safety orientation program

To assess the ability of nurses to identify medication errors and apply strategies to prevent adverse drug events.