Penny J. Lewis

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.

A systematic review of the prevalence and incidence of prescribing errors with high-risk medicines in hospitals

Prescribing errors are the most common type of error in the medication use process. However, there is a paucity of literature regarding the prevalence or incidence of prescribing errors in high‐risk medicines (HRMs). HRMs bear a heightened risk of causing significant patient harm when they are used in error.

A comparison of the causes of FY1 and FY2 Trainees' prescribing errors: A Preliminary Analysis

PRESCRIBING AND RESEARCH IN MEDICINES MANAGEMENT (UK & IRELAND)

Practice makes perfect: A systematic review of the expertise development of pharmacist and nurse independent prescribers in the United Kingdom

Background Prescribing is a complex and error‐prone task that demands expertise. McLellan et al.s theory of expertise development model (“the model”), developed to assess medical literature on prescribing by medical students, proposes that in order to develop, individuals should deliberately engage their knowledge, skills and attitudes within a social context. Its applicability to independent prescribers (IP) is unknown. Aim A systematic review was conducted to explore whether the model is applicable to non‐medical independent prescribing and to assess the factors underpinning expertise development reported in the literature. Method Six electronic databases (EMBASE, Medline, AMED, CINAHL, IPA and PsychInfo) were searched for articles published between 2006 and 2016, reporting empirical data on pharmacist and nurse IPs education or practice. Data were extracted using themes from the model and analysed using framework analysis. Results Thirty‐four studies met the inclusion criteria. Knowledge, pre‐registration education, experience, support and confidence were some of the intrinsic and extrinsic factors influencing IPs. Difficulty in transferring theory to practice was attributed to lack of basic pharmacology and bioscience content in pre‐registration nursing rather than the prescribing programme. Students saw interventions using virtual learning or learning in practice as more useful with long‐term benefits e.g. students were able to use their skills in history taking following the virtual learning intervention 6‐months after the programme. All studies demonstrated how engaging knowledge and skills affected individuals’ attitude by, for example, increasing professional dignity. IPs were able to develop their expertise when integrating their competencies in a workplace context with support from colleagues and adherence to guidelines. Conclusion This is the first study to synthesize data systematically on expertise development from studies on IPs using the model. The model showed the need for stronger foundations in scientific knowledge amongst some IPs, where continuous workplace practice can improve skills and strengthen attitudes. This could facilitate a smoother transfer of learnt theory to practice, in order for IPs to be experts within their fields and not merely adequately competent. HighlightsThe theory of expertise development model is an alternate approach to prescribing education.Pharmacist and nurse independent prescribers and those learning to prescribe have difficulty applying theory to practice.Pharmacist and nurse independent prescribers are influenced by the added responsibility of prescribing.Experience facilitates the understanding of theory and strengthens attitudes.The theory of expertise development model is applicable to pharmacist and nurse independent prescribers in the UK.

Mindful organizing in patients’ contributions to primary care medication safety

There is a need to ensure that the risks associated with medication usage in primary health care are controlled. To maintain an understanding of the risks, health‐care organizations may engage in a process known as “mindful organizing.” While this is typically conceived of as involving organizational members, it may in the health‐care context also include patients. Our study aimed to examine ways in which patients might contribute to mindful organizing with respect to primary care medication safety.

Junior doctors’ communication with hospital pharmacists about prescribing: findings from a qualitative interview study

Objectives To explore factors affecting communication between Foundation Year (FY) 1 doctors and hospital pharmacists about prescribing from the junior doctors’ perspective. Methods Trained interviewers (n=4) conducted semistructured interviews with FY1 doctors who were purposively sampled from three hospitals in England. FY1 doctors were asked about their experiences of communication with hospital pharmacists about their prescribing; instances where they disagreed with or did not implement a hospital pharmacist’s recommendation; and their preferences for communicating with hospital pharmacists about prescribing. Interviews were audiorecorded, transcribed verbatim and analysed thematically. Results A total of 27 FY1 doctors were interviewed. Findings were categorised into four main themes: (1) nature and context of communication; (2) FY1 doctors’ perceptions of communication with hospital pharmacists; (3) factors influencing FY1 doctors’ decision whether to act on pharmacists’ prescribing recommendations; and (4) suggestions to improve communication with pharmacists. FY1 doctors and hospital pharmacists generally communicated well. FY1 doctors appreciated and frequently acted on pharmacists’ advice yet there was deference to senior medical staff when advice differed. Joint ward rounds, pharmacist-led teaching sessions and a standardised approach to communication were all suggested as ways to improve communication and may increase the likelihood of pharmacists’ recommendations being acted on. Conclusions FY1 doctors and hospital pharmacists communicated frequently about medication prescribing. Issues occurred when there were differences in professional judgement between senior medical staff and pharmacists but these were usually resolved satisfactorily for the FY1 doctor. Further interventions to improve communication and safe prescribing could involve a multidisciplinary and systems approach.

Patient prioritization for pharmaceutical care in hospital: A systematic review of assessment tools

BACKGROUND Clinical pharmacy services improve patient safety, outcomes, and care quality; however, UK clinical pharmacy services face limited resources, insufficient capacity, and patients who present with increasingly complex medication regimes and morbidities. These indicate a need for the prioritization of pharmacy services. Several prioritization tools have been developed; however, there has been no comprehensive review of such tools to date. OBJECTIVE A systematic review was conducted to provide a structured overview and description of existing assessment tools with a focus on study quality, themes, tool validity, risk factors, and high-risk drug classes. METHODS Systematic searches for English-language publications (from 1990 to September 2017) were conducted in Embase, Medline, Scopus, International Pharmaceutical Abstracts, and Web of Science. Papers in the inpatient setting and in which the tool users were pharmacists or pharmacy technicians were included. Data on each study (e.g. aim and design) and the structure of tools (e.g. risk factors) from each included study were extracted by 2 independent reviewers. A descriptive analysis was conducted to summarize these tools along with a thematic analysis of study findings. The quality of each paper was assessed using the Hawker method. RESULTS Nineteen studies involving 17 risk assessment tools were included. Most tools were developed in Europe (76.5%) and published in the last 5 years (82%). Most tools (88%) were designed to identify patients at greatest risk of adverse drug reactions, adverse drug events, or medication errors and to guide appropriate pharmaceutical care. Ten out of 17 tools (59%) were validated. None showed a measurable impact on prescription errors or adverse drug events. Keys themes identified from the studies were the positive impact of risk assessment tools on both patient care and provision of pharmacy services as well as the limitations of risk assessment tools. CONCLUSIONS Current assessment tools are heterogeneous in their content, targeting diverse patient groups and clinical settings making generalization difficult. However, an underlying theme of all studies was that tools appear to achieve their aim in directing pharmaceutical care to where it is needed most which might provide reassurance and incentive for greater adoption and development of tools across clinical pharmacy services. However, further research is required to measure objectively the impact of tools on patient outcomes and on workforce efficiency so that comparisons can be made between tools.

Factors influencing secondary care pharmacist and nurse independent prescribers’ clinical reasoning: An interprofessional analysis

ABSTRACT In the United Kingdom, pharmacist and nurse independent prescribers are responsible for both the clinical assessment of and prescribing for patients. Prescribing is a complex skill that entails the application of knowledge, skills, and clinical reasoning to arrive at a clinically appropriate decision. Decision-making is influenced and informed by many factors. This study, the first of its kind, explores what factors influence pharmacist and nurse independent prescribers during the process of clinical reasoning. A think-aloud methodology immediately followed by a semi-structured interview was conducted with 11 active nurse and 10 pharmacist independent prescribers working in secondary care. Each participant was presented with validated clinical vignettes for the think-aloud stage. Participants chose the clinical therapeutic areas for the vignettes, based on their self-perceived competencies. Data were audio-recorded, transcribed verbatim, and a constant-comparative approach was used for analysis. Influences on clinical reasoning were broadly categorised into themes: social interaction, intrinsic, and contextual factors. These themes showed that intrinsic, sociocultural, and contextual aspects heavily influenced the clinical reasoning processes of prescribers. For example, prescribers were aware of treatment pathways, but chose to refer patient cases to avoid making the final prescribing decision. Exploration of this behaviour in the interviews revealed that previous experience and attitudes such as confidence and cautiousness associated with responsibility were strong influencers within the decision-making process. In addition, strengthening the professional identity of prescribers could be achieved through collaborative work with interprofessional healthcare teams to orient their professional practice from within the profession. Findings from this study can be used to inform the education, training, and practice of independent prescribers to improve healthcare services by improving their professional and interprofessional development.

Exploring the experiences and opinions of hospital pharmacists working 24/7 shifts

Objectives The expansion of out-of-hours pharmacy services results from a drive to improve patient care and promote integration into the wider healthcare team. However, there has been little attempt to explore these intended outcomes as well as the potential problems arising from working out of hours. The aim of this study was to explore the experiences and views of pharmacists who work shifts as part of a 24/7 pharmacy service. Methods Semistructured interviews with shift-working pharmacists were conducted. Data were analysed using a framework approach. Results Pharmacists described the positive impact they had on patient safety by ensuring the prompt supply of time-critical medicines and their proactive role in preventing adverse drug events. Pharmacists’ on-site presence and attendance at handover promoted integration into the wider team and facilitated unplanned interventions. However, requests for non-urgent supplies were a source of frustration. Disparity of pharmacists’ perceptions of senior support demonstrated a need to explore communication further and the importance of non-technical skills, such as communication in service provision. Shift work appeared to be a double-edged sword for work–life balance, preventing participation in regular hobbies, but providing flexibility. Service improvements could include technician support, greater feedback provision and improved ordering processes. Conclusions Overall, pharmacists believed the shift service exhibited numerous advantages over a traditional remote on-call service, particularly in improving aspects of patient safety and integration into the wider healthcare team. Clarity of the service scope and development of non-technical skills are areas for improvement and development.