Mary P. Tully

Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review.

Prescribing errors affect patient safety throughout hospital practice. Previous reviews of studies have often targeted specific populations or settings, or did not adopt a systematic approach to reviewing the literature. Therefore, we set out to systematically review the prevalence, incidence and nature of prescribing errors in hospital inpatients. MEDLINE, EMBASE, CINAHL and International Pharmaceutical Abstracts (all from 1985 to October 2007) were searched for studies of prescriptions for adult or child hospital inpatients giving enough data to calculate an error rate. Electronic prescriptions and errors for single diseases, routes of administration or types of prescribing error were excluded, as were non-English language publications. Median error rate (interquartile range [IQR]) was 7% (2–14%) of medication orders, 52 (8–227) errors per 100 admissions and 24 (6–212) errors per 1000 patient days. Most studies (84%) were conducted in single hospitals and originated from the US or UK (72%). Most errors were intercepted and reported before they caused harm, although two studies reported adverse drug events. Errors were most common with antimicrobials and more common in adults (median 18% of orders [ten studies, IQR 7–25%]) than children (median 4% [six studies, IQR 2–17%]). Incorrect dosage was the most common error.Overall, it is clear that prescribing errors are a common occurrence, affecting 7% of medication orders, 2% of patient days and 50% of hospital admissions. However, the reported rates of prescribing errors varied greatly and this could be partly explained by variations in the definition of a prescribing error, the methods used to collect error data and the setting of the study. Furthermore, a lack of standardization between severity scales prevented any comparison of error severity across studies. Future research should address the wide disparity of data-collection methods and definitions that bedevils comparison of error rates or meta-analysis of different studies.

The Causes of and Factors Associated with Prescribing Errors in Hospital Inpatients: A Systematic Review

Prescribing errors are common, they result in adverse events and harm to patients and it is unclear how best to prevent them because recommendations are more often based on surmized rather than empirically collected data. The aim of this systematic review was to identify all informative published evidence concerning the causes of and factors associated with prescribing errors in specialist and non-specialist hospitals, collate it, analyse it qualitatively and synthesize conclusions from it.Seven electronic databases were searched for articles published between 1985–July 2008. The reference lists of all informative studies were searched for additional citations. To be included, a study had to be of handwritten prescriptions for adult or child inpatients that reported empirically collected data on the causes of or factors associated with errors. Publications in languages other than English and studies that evaluated errors for only one disease, one route of administration or one type of prescribing error were excluded.Seventeen papers reporting 16 studies, selected from 1268 papers identified by the search, were included in the review. Studies from the US and the UK in university-affiliated hospitals predominated (10/16 [62%]). The definition of a prescribing error varied widely and the included studies were highly heterogeneous. Causes were grouped according to Reason’s model of accident causation into active failures, error-provoking conditions and latent conditions. The active failure most frequently cited was a mistake due to inadequate knowledge of the drug or the patient. Skills-based slips and memory lapses were also common. Where error-provoking conditions were reported, there was at least one per error. These included lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between healthcare professionals. Latent conditions included reluctance to question senior colleagues and inadequate provision of training.Prescribing errors are often multifactorial, with several active failures and error-provoking conditions often acting together to cause them. In the face of such complexity, solutions addressing a single cause, such as lack of knowledge, are likely to have only limited benefit. Further rigorous study, seeking potential ways of reducing error, needs to be conducted. Multifactorial interventions across many parts of the system are likely to be required.

Pharmacists’ Interventions in Prescribing Errors at Hospital Discharge

AbstractBackground: Pharmacists have an essential role in improving drug usage and preventing prescribing errors (PEs). PEs at the interface of care are common, sometimes leading to adverse drug events (ADEs). This was the first study to investigate, using a computerized search method, the number, types, severity, pharmacists’ impact on PEs and predictors of PEs in the context of electronic prescribing (e-prescribing) at hospital discharge. Method: This was a retrospective, observational, 4-week study, carried out in 2008 in the Medical and Elderly Care wards of a 904-bed teaching hospital in the northwest of England, operating an e-prescribing system at discharge. Details were obtained, using a systematic computerized search of the system, of medication orders either entered by doctors and discontinued by pharmacists or entered by pharmacists. Meetings were conducted within 5 days of data extraction with pharmacists doing their routine clinical work, who categorized the occurrence, type and severity of their interventions using a scale. An independent senior pharmacist retrospectively rated the severity and potential impact, and subjectively judged, based on experience, whether any error was a computer-related error (CRE). Discrepancies were resolved by multidisciplinary discussion. The Statistical Package for Social Sciences was used for descriptive data analysis. For the PE predictors, a multivariate logistic regression was performed using STATA® 7. Nine predictors were selected a priori from available prescribers’, patients’ and drug data. Results: There were 7920 medication orders entered for 1038 patients (doctors entered 7712 orders; pharmacists entered 208 omitted orders). There were 675 (8.5% of 7920) interventions by pharmacists; 11 were not associated with PEs. Incidences of erroneous orders and patients with error were 8.0% (95% CI 7.4, 8.5 [n = 630/7920]) and 20.4% (95% CI 18.1, 22.9 [n = 212/1038]), respectively. The PE incidence was 8.4% (95% CI 7.8, 9.0 [n = 664/7920]). The top three medications associated with PEs were paracetamol (acetaminophen; 30 [4.8%]), salbutamol (albuterol; 28 [4.4%]) and omeprazole (25 [4.0%]). Pharmacists intercepted 524 (83.2%) erroneous orders without referring to doctors, and 70% of erroneous orders within 24 hours. Omission (31.0%), drug selection (29.4%) and dosage regimen (18.1%) error types accounted for >75% of PEs. There were 18 (2.9%) serious, 481 (76.3%) significant and 131 (20.8%) minor erroneous orders. Most erroneous orders (469 [74.4%]) were rated as of significant severity and significant impact of pharmacists on PEs. CREs (n = 279) accounted for 44.3% of erroneous orders. There was a significant difference in severity between CREs and non-CREs (χ2= 38.88; df=4; p<0.001), with CREs being less severe than non-CREs. Drugs with multiple oral formulations (odds ratio [OR] 2.1; 95% CI 1.25, 3.37; p = 0.004) and prescribing by junior doctors (OR 2.54; 95% CI 1.08, 5.99; p = 0.03) were significant predictors of PEs. Conclusions: PEs commonly occur at hospital discharge, even with the use of an e-prescribing system. User and computer factors both appeared to contribute to the high error rate. The e-prescribing system facilitated the systematic extraction of data to investigate PEs in hospital practice. Pharmacists play an important role in rapidly documenting and preventing PEs before they reach and possibly harm patients. Pharmacists should understand CREs, so they complement, rather than duplicate, the e-prescribing system’s strengths.

Provision of pharmaceutical care by community pharmacists: a comparison across Europe

Objective To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation. Methods A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities). Results Response rates ranged from 10–71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care. Conclusion The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

How to use the nominal group and Delphi techniques

Introduction The Nominal Group Technique (NGT) and Delphi Technique are consensus methods used in research that is directed at problem-solving, idea-generation, or determining priorities. While consensus methods are commonly used in health services literature, few studies in pharmacy practice use these methods. This paper provides an overview of the NGT and Delphi technique, including the steps involved and the types of research questions best suited to each method, with examples from the pharmacy literature. Methodology The NGT entails face-to-face discussion in small groups, and provides a prompt result for researchers. The classic NGT involves four key stages: silent generation, round robin, clarification and voting (ranking). Variations have occurred in relation to generating ideas, and how ‘consensus’ is obtained from participants. The Delphi technique uses a multistage self-completed questionnaire with individual feedback, to determine consensus from a larger group of ‘experts.’ Questionnaires have been mailed, or more recently, e-mailed to participants. When to use The NGT has been used to explore consumer and stakeholder views, while the Delphi technique is commonly used to develop guidelines with health professionals. Method choice is influenced by various factors, including the research question, the perception of consensus required, and associated practicalities such as time and geography. Limitations The NGT requires participants to personally attend a meeting. This may prove difficult to organise and geography may limit attendance. The Delphi technique can take weeks or months to conclude, especially if multiple rounds are required, and may be complex for lay people to complete.

The effect of gender on medical students’ aspirations: a qualitative study

Objective  This study aimed to explore the effect of gender on medical students’ aspirations.

Impact of Pharmacists Providing a Prescription Review and Monitoring Service in Ambulatory Care or Community Practice

OBJECTIVE: To systematically review the impact, on patient outcomes and costs to the healthcare system, of pharmacists reviewing and monitoring prescribing in ambulatory care or community practice. DATA SOURCES: We conducted a systematic search of published literature, up to and including 1998, on outcomes of prescription monitoring and review by pharmacists. Thirteen electronic databases were reviewed, along with a hand search of 11 journals known to publish pharmacy practice research. Fifty-five articles describing 50 comparative studies were identified. DATA EXTRACTION: Data were extracted including study design, clinical site, and results. A qualitative synthesis of the findings was conducted and methodological quality was appraised. DATA SYNTHESIS: Pharmacist-run services may be accompanied by improvements in clinical outcomes. Inconsistent definitions used in the research evaluated meant that an overall interpretation of a change in the incidence of compliance and adverse drug reactions was impossible. Other outcomes such as knowledge and satisfaction showed equivocal results overall. There was little or no change in quality of life where this was assessed. Savings in drug acquisition costs may have accrued, but it was impossible to calculate the magnitude. Pharmacist involvement produced a positive impact on cost—benefit and cost-effectiveness. CONCLUSIONS: The heterogeneity of the studies found and the variety in quality of much of the research design prevent the rigorous assessment of the direction and magnitude of any changes reviewed. Further studies are required, which must be rigorously designed, with blind and independent assessment of clearly defined outcomes. In particular, there is a need to investigate the effect of such services on the incidence of adverse drug reactions and quality of life and to conduct robust cost—benefit analyses.

Adherence to treatment in Swedish HIV-infected patients

Objectives:  The objectives were to assess the prevalence of adherence to antiretroviral treatment in Swedish human immunodeficiency virus (HIV)‐infected patients and to evaluate factors associated with adherence.

Implementation of a pharmaceutical care service: prescriptionists’, pharmacists’ and doctors’ views

ObjectiveTo identify prescriptionists’, pharmacists’ and doctors’ perceptions and experiences of a pharmaceutical care service supported by patient medication records (PMRs).MethodQualitative study employing focus group interviews with 16 prescriptionists and five pharmacists, and semi structured telephone interviews with 11 doctors.Main outcome measuresPrescriptionists’, pharmacists’ and doctors’ views, experiences and perceptions of a pharmaceutical care service on Swedish community pharmacies.ResultsThe provision of pharmaceutical care aided by PMRs had a positive influence on the prescriptionists’ and pharmacists’ daily work, and on their view of their professional role. They assumed greater professional responsibility, and described greater use of their pharmaceutical knowledge, greater confidence in practice and an increased awareness of their counselling role. They appreciated that the pharmaceutical care service provided an over-all picture of patients’ drug use, allowed for follow-up on counselling and made the prescriptionists’ and pharmacists’ competence tangible for patients. Perceived problems with the pharmaceutical care service included being time-consuming, record keeping being difficult, difficulty in getting understanding/support from colleagues and managers, and difficulty involving doctors. The majority of the doctors reported that they had not taken an active interest in the project, and their opinions of the pharmaceutical care service varied.ConclusionWhen prescriptionists and pharmacists apply the pharmaceutical care concept and work with PMRs, the patients are more likely to meet confident professionals that are more aware of the individual behind the drug therapy. This will hopefully contribute to informed, motivated medicine users that feel secure in their interactions with their pharmacy and receive, not only drugs, but treatment support. For such a service to be effective, however, it is vital to ensure that the doctors are fully co-operative.

Long term clinical outcome of home and hospital intravenous antibiotic treatment in adults with cystic fibrosis

Background: Several studies have suggested that clinical outcomes in adults with cystic fibrosis (CF) are equivalent after home and hospital treatment with intravenous antibiotics, but these studies were small and selective and only considered one course of treatment. Methods: A retrospective longitudinal study was performed to compare the clinical outcome over a period of 1 year of all patients attending the Manchester Adult CF Unit who received intravenous antibiotics at home or in hospital. The primary outcome measure was percentage change in forced expiratory volume in 1 second (FEV1) at the end of the 1 year period. Baseline “best” and “average” FEV1 values were established for each patient for the year before the study. The secondary outcome measures were percentage changes in forced vital capacity (FVC) and body weight. Results: A total of 116 patients received 454 courses of intravenous antibiotics. At the end of 1 year there had been a mean percentage decline in FEV1 compared with the baseline “average” for patients treated mostly at home but an improvement in patients treated mostly in hospital (Tukey’s HSD mean difference 10.1%, 95% CI 2.9 to 17.2, p = 0.003). For all patients there was a mean percentage decline in FEV1 from the baseline “best” value. For each course of treatment the mean percentage improvements in FEV1 at the end of the course from the start of the course were significantly higher for patients treated in hospital than for those treated at home. Conclusions: Clinical outcome, as defined by spirometric parameters and body weight, was better after a course of treatment in hospital than after home treatment, and this benefit was maintained over 1 year of treatment. The results suggest that patients treated at home need closer supervision.