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Reducing prescription errors
Correspondence
Department of Health to introduce one as soon as possible. We declare that we have no conflicts of interest.
*Tony Weetman, Jeffrey Aronson, Simon Maxwell a.p.weetman@sheffield.ac.uk Medical Schools Council, London WC1H 9HD, UK (TW); and British Pharmacological Society, London, UK (JA, AM) 1 2
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The printed journal includes an image merely for illustration
462
The Lancet. How to reduce prescribing errors. Lancet 2009; 374: 1945. Medical Schools Council. Outcomes of the Medical Schools Council Safe Prescribing Working Group. http://www.medschools.ac.uk/ Publications/Pages/Safe-Prescribing-WorkingGroup-Outcomes.aspx (accessed Jan 20, 2010).
Your Editorial1 discussing the EQUIP report makes recommendations for the standardisation of prescription charts and enhanced interprofessional teaching of therapeutics and pharmacology to reduce prescribing errors. Although we concur with these suggestions, the standard medication and e-learning package in Wales to which you refer lacks evidence to support any reduction in prescribing errors. In Queensland, Australia, a multidisciplinary collaborative has been improving medication safety for 10 years. From its inception, our work has been based on robust error analysis2 and assessment of system improvements, one of which has been a standard inpatient medication chart.3 The chart had three objectives: (1) to reduce errors due to unfamiliarity with systems when staff rotate; (2) to provide decision support and reduce risks in communicating prescribing to pharmacy, nursing, and other medical staff; and (3) to enable structured practical prescribing education and training for students using the system that they will all be exposed to as practitioners. A study of almost 10 000 orders before and after the chart’s implementation across five sites showed a significant absolute reduction in prescribing errors of 4·2% per patient. Clinical benefits included significant reductions in patients re-exposed to drugs that caused a previous adverse
reaction, safer dosing and frequency instructions, and improved warfarin management.3 The chart was subsequently adopted as the Australian National Inpatient Medication Chart and showed similar benefits in prescribing error reduction in a 31-site national pilot study.4 A programme of tutorials on safe medication practice was then trialled for final-year medical students, which showed significantly safer prescribing in the intervention cohort.5 We declare that we have no conflicts of interest.
*Ian Coombes, Carol Reid, Danielle Stowasser, Margaret Duigiud, Graham Bedford, Charles Mitchell [email protected] Centre for Safe and Effective Prescribing, University of Queensland, Brisbane, QLD 4102, Australia (IC, DS, CM); Safe Medication Management Unit, Medication Services Queensland, Brisbane, QLD, Australia (IC, CR); and Australian Commission on Safety and Quality in Health Care, Sydney, NSW, Australia (MD, GB) 1 2
3
4
5
The Lancet. How to reduce prescribing errors. Lancet 2009; 374: 1945. Coombes ID, Stowasser DA, Coombes JA, Mitchell C. Why do interns make prescribing errors? A qualitative study. MJA 2008; 188: 89–94. Coombes ID, Stowasser DA, Reid C, Mitchell C. Impact of a standard medication chart on prescribing; a before and after audit. Qual Saf Health Care 2009; 18: 478–85. Australian Council for Safety and Quality in Health Care. Australian Council for Safety and Quality in Health Care national inpatient medication chart pilot aggregate data report. http://www.safetyandquality.gov.au/internet/ safety/publishing.nsf/Content/80A0EF37F281 A8D7CA25718F000CCC2F/$File/chaggreg.pdf (accessed Jan 20, 2010). Coombes I, Mitchell C, Stowasser D. Safe medication practice tutorials; a practical approach to preparing prescribers. Clin Teacher 2007; 4: 128–34.
of our prescribing would be through electronic prescribing. I have the benefit of working in one of the few UK hospitals where electronic prescribing, albeit a rather primitive type with no supportive tools, has been implemented. With this system, all prescription records, drug names, and doses are clearly legible. If appropriate, new medications can be added, changed, or deleted without having to go back physically to the ward where the patient is. For me, a consultant microbiologist, electronic prescribing is really useful, because I can monitor more easily which antibiotics patients are on, and I can intervene more easily and promptly if antibiotic changes are required. Unfortunately, our very basic system would not prevent a doctor from prescribing the wrong dose or failing to recognise potential adverse interaction between medications. Nor are there are any alerts to recommend dose reductions (or discontinuation) for patients with renal impairment or liver disease, or to flag up allergies. After so much money has been spent (or wasted?) in the UK on clinically irrelevant “connecting for health” information technology, it is a pity that so little has been invested to allow the implementation of intelligent electronic prescribing tools which could eliminate, or at least reduce, one of the most common sources of errors and critical incidents in the NHS. I declare that I have no conflicts of interest.
Giuseppe E Bignardi [email protected]
Your Dec 12 Editorial refers to a report that found an overall prescription error rate in the UK National Health Service (NHS) of 8·9%. The main recommendation in this report seems to have been the introduction of a standard drug chart throughout the NHS. No doubt this would be an improvement, but it hardly seems a major one. It appears to me that the only way to achieve a major leap in the quality 1
Microbiology Department, Sunderland Royal Hospital, Sunderland SR4 7TP, UK 1
The Lancet. How to reduce prescribing errors. Lancet 2009; 374: 1945.
www.thelancet.com Vol 375 February 6, 2010
Department of Health to introduce one as soon as possible. We declare that we have no conflicts of interest.
*Tony Weetman, Jeffrey Aronson, Simon Maxwell a.p.weetman@sheffield.ac.uk Medical Schools Council, London WC1H 9HD, UK (TW); and British Pharmacological Society, London, UK (JA, AM) 1 2
iStockphoto
The printed journal includes an image merely for illustration
462
The Lancet. How to reduce prescribing errors. Lancet 2009; 374: 1945. Medical Schools Council. Outcomes of the Medical Schools Council Safe Prescribing Working Group. http://www.medschools.ac.uk/ Publications/Pages/Safe-Prescribing-WorkingGroup-Outcomes.aspx (accessed Jan 20, 2010).
Your Editorial1 discussing the EQUIP report makes recommendations for the standardisation of prescription charts and enhanced interprofessional teaching of therapeutics and pharmacology to reduce prescribing errors. Although we concur with these suggestions, the standard medication and e-learning package in Wales to which you refer lacks evidence to support any reduction in prescribing errors. In Queensland, Australia, a multidisciplinary collaborative has been improving medication safety for 10 years. From its inception, our work has been based on robust error analysis2 and assessment of system improvements, one of which has been a standard inpatient medication chart.3 The chart had three objectives: (1) to reduce errors due to unfamiliarity with systems when staff rotate; (2) to provide decision support and reduce risks in communicating prescribing to pharmacy, nursing, and other medical staff; and (3) to enable structured practical prescribing education and training for students using the system that they will all be exposed to as practitioners. A study of almost 10 000 orders before and after the chart’s implementation across five sites showed a significant absolute reduction in prescribing errors of 4·2% per patient. Clinical benefits included significant reductions in patients re-exposed to drugs that caused a previous adverse
reaction, safer dosing and frequency instructions, and improved warfarin management.3 The chart was subsequently adopted as the Australian National Inpatient Medication Chart and showed similar benefits in prescribing error reduction in a 31-site national pilot study.4 A programme of tutorials on safe medication practice was then trialled for final-year medical students, which showed significantly safer prescribing in the intervention cohort.5 We declare that we have no conflicts of interest.
*Ian Coombes, Carol Reid, Danielle Stowasser, Margaret Duigiud, Graham Bedford, Charles Mitchell [email protected] Centre for Safe and Effective Prescribing, University of Queensland, Brisbane, QLD 4102, Australia (IC, DS, CM); Safe Medication Management Unit, Medication Services Queensland, Brisbane, QLD, Australia (IC, CR); and Australian Commission on Safety and Quality in Health Care, Sydney, NSW, Australia (MD, GB) 1 2
3
4
5
The Lancet. How to reduce prescribing errors. Lancet 2009; 374: 1945. Coombes ID, Stowasser DA, Coombes JA, Mitchell C. Why do interns make prescribing errors? A qualitative study. MJA 2008; 188: 89–94. Coombes ID, Stowasser DA, Reid C, Mitchell C. Impact of a standard medication chart on prescribing; a before and after audit. Qual Saf Health Care 2009; 18: 478–85. Australian Council for Safety and Quality in Health Care. Australian Council for Safety and Quality in Health Care national inpatient medication chart pilot aggregate data report. http://www.safetyandquality.gov.au/internet/ safety/publishing.nsf/Content/80A0EF37F281 A8D7CA25718F000CCC2F/$File/chaggreg.pdf (accessed Jan 20, 2010). Coombes I, Mitchell C, Stowasser D. Safe medication practice tutorials; a practical approach to preparing prescribers. Clin Teacher 2007; 4: 128–34.
of our prescribing would be through electronic prescribing. I have the benefit of working in one of the few UK hospitals where electronic prescribing, albeit a rather primitive type with no supportive tools, has been implemented. With this system, all prescription records, drug names, and doses are clearly legible. If appropriate, new medications can be added, changed, or deleted without having to go back physically to the ward where the patient is. For me, a consultant microbiologist, electronic prescribing is really useful, because I can monitor more easily which antibiotics patients are on, and I can intervene more easily and promptly if antibiotic changes are required. Unfortunately, our very basic system would not prevent a doctor from prescribing the wrong dose or failing to recognise potential adverse interaction between medications. Nor are there are any alerts to recommend dose reductions (or discontinuation) for patients with renal impairment or liver disease, or to flag up allergies. After so much money has been spent (or wasted?) in the UK on clinically irrelevant “connecting for health” information technology, it is a pity that so little has been invested to allow the implementation of intelligent electronic prescribing tools which could eliminate, or at least reduce, one of the most common sources of errors and critical incidents in the NHS. I declare that I have no conflicts of interest.
Giuseppe E Bignardi [email protected]
Your Dec 12 Editorial refers to a report that found an overall prescription error rate in the UK National Health Service (NHS) of 8·9%. The main recommendation in this report seems to have been the introduction of a standard drug chart throughout the NHS. No doubt this would be an improvement, but it hardly seems a major one. It appears to me that the only way to achieve a major leap in the quality 1
Microbiology Department, Sunderland Royal Hospital, Sunderland SR4 7TP, UK 1
The Lancet. How to reduce prescribing errors. Lancet 2009; 374: 1945.
www.thelancet.com Vol 375 February 6, 2010