Sarah K. Thomas

Developing consensus on hospital prescribing indicators of potential harms amenable to decision support

AIMS To develop a list of prescribing indicators specific for the hospital setting that would facilitate the prospective collection of high-severity and/or high-frequency prescribing errors, which are also amenable to electronic clinical decision support. METHODS A two-stage consensus technique (electronic Delphi) was carried out with 20 experts across England. Participants were asked to score prescribing errors using a five-point Likert scale for their likelihood of occurrence and the severity of the most likely outcome. These were combined to produce risk scores, from which median scores were calculated for each indicator across the participants in the study. The degree of consensus between the participants was defined as the proportion that gave a risk score in the same category as the median. Indicators were included if a consensus of 80% or more was achieved. RESULTS A total of 80 prescribing errors were identified by consensus as being high or extreme risk. The most common drug classes named within the indicators were antibiotics (n = 13), antidepressants (n = 8), nonsteroidal anti-inflammatory drugs (n = 6) and opioid analgesics (n = 6). The most frequent error type identified as high or extreme risk were those classified as clinical contraindications (n = 29 of 80). CONCLUSIONS Eighty high-risk prescribing errors in the hospital setting have been identified by an expert panel. These indicators can serve as a standardized, validated tool for the collection of prescribing data in both paper-based and electronic prescribing processes. This can assess the impact of safety improvement initiatives, such as the implementation of electronic clinical decision support.

Temporal and other factors that influence the time doctors take to prescribe using an electronic prescribing system

BACKGROUND A computerized physician order entry (CPOE) system with embedded clinical decision support can reduce medication errors in hospitals, but might increase the time taken to generate orders. AIMS We aimed to quantify the effects of temporal (month, day of week, hour of shift) and other factors (grade of doctor, prior experience with the system, alert characteristics, and shift type) on the time taken to generate a prescription order. SETTING A large university teaching hospital using a locally developed CPOE system with an extensive audit database. DESIGN We retrospectively analyzed prescription orders from the audit database between August 2011 and July 2012. RESULTS The geometric mean time taken to generate a prescription order within the CPOE system was 11.75 s (95% CI 11.72 to 11.78). Time to prescribe was most affected by the display of high-level (24.59 s (24.43 to 24.76); p<0.001) or previously unseen (18.87 s (18.78 to 18.96); p<0.001) alerts. Prescribers took significantly less time at weekends (11.29 s (11.23 to 11.35)) than on weekdays (11.88 s (11.84 to 11.91); p<0.001), in the first (11.25 s (11.16 to 11.34); p<0.001) and final (11.56 s (11.47 to 11.66); p<0.001) hour of their shifts, and after the first month of using the system. CONCLUSIONS The display of alerts, prescribing experience, system familiarity, and environment all affect the time taken to generate a prescription order. Our study reinforces the need for appropriate alerts to be presented to individuals at an appropriate place in the workflow, in order to improve prescribing efficiency.

A practical guide to monitoring for adverse drug reactions during antihypertensive drug therapy

Summary Monitoring of patients taking antihypertensive treatment can identify potential adverse drug reactions (ADRs). However, published guidelines give divergent or incomplete recommendations on monitoring for ADRs. Using a predetermined strategy, we undertook a systematic review to identify hypertension guidelines published from January 2001 to October 2011 with recommendations for monitoring for ADRs. We screened 88 abstracts and 187 web-based guidelines, and identified 19 published guidelines on monitoring the biochemical effects of antihypertensive drug therapy. We then produced a set of practical clinical guidelines, synthesized from those recommendations. Our recommendations are designed to provide efficient monitoring. They reduce the number of tests to a minimum consistent with safe practice and align monitoring schedules, so that creatinine, potassium and sodium concentrations are measured at the same times in all cases. The instructions for biochemical monitoring in current guidelines differ greatly, both in the extent of advice and in the detail provided. The current lack of consistent and workable instructions poses serious difficulties for practitioners. The recommendations distilled from this systematic review should help practitioners when they monitor therapy with antihypertensive drugs.

Variation in cost of newly qualified doctors’ prescriptions: a review of data from a hospital electronic prescribing system

Purpose of the study To investigate the variation in the net ingredient cost (NIC) of the medications most commonly prescribed by Foundation Year 1 (F1) doctors in a teaching hospital and to compare the effects of working in different specialties and rotations on this cost. Design of the study Retrospective review of prescription data from 5 August 2010 to 3 August 2011 extracted from an electronic prescribing system. Results The F1 doctors generated 81 316 prescriptions with an estimated total cost of £579 398. The mean NIC per doctor was £7334 (SE=£430). Prescribing costs varied significantly across clinical departments and between drug classes considered in the analysis. Specifically, prescribing in the infection and respiratory drug categories and within the trauma and orthopaedics department was associated with higher prescribing costs. Significant variability was also attributable to the prescribing doctor (p<0.001) with average prescription costs ranging from 72.2% lower to 193.8% higher than the median doctor. Conclusions There is considerable variation in the total costs of medications prescribed by F1 doctors, even after considering a range of prescription factors. This variation may suggest that some doctors are prescribing uneconomically relative to the rest of the cohort. Knowledge of which clinical areas and drug classes have higher NICs may allow an alternative focus for medicine management teams and postgraduate education.

The impact of computerised physician order entry with integrated clinical decision support on pharmacist–physician communication in the hospital setting: a systematic review of the literature

Objective To document the issues and impact that computerised physician order entry (CPOE) with clinical decision support (CDS) can have on pharmacist–physician communication in the hospital setting. Hypothesis Novel processes introduced by CPOE systems with integrated CDS bring the potential to change face-to-face communication between the pharmacist and physician, and therefore affect their clinical interactions. The authors believe that virtual communications between healthcare providers and the content of CDS alerts may lead to a shift in traditional pharmacist–physician communications worthy of further study. Methodology MEDLINE, EMBASE and PubMed (1947–November 2011) were searched using subject headings and relevant free text terms. The language and date of publication were not defined. The studies were assessed for their quality, and the content of the articles was analysed in full and categorised to allow for a structured narrative review. Results A total of 48 papers were identified, of which 24 were excluded based on the title and abstract. Of the 24 papers reviewed in full text, seven were selected for inclusion. Several topics emerged from the review: computer entry: ‘a false communication’; interpersonal communication; the impact of pharmacist messages in an electronic format; physician accessibility to pharmacist alerts; and the effect of decision support on communication. Conclusions Few studies have examined the impact of CPOE and CDS technologies on pharmacist–physician communication in the hospital setting. Furthermore, there has been no research to date that looks specifically at how CDS affects what is communicated by pharmacists as alerts. Research into this area could provide a valuable insight into how communication channels in existing systems can be enhanced so that inter-professional interactions are optimised to benefit patient care.