Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting

BackgroundPrescribing errors are prevalent in hospital settings with provision of feedback recommended to support prescribing of doctors. Feedback on prescribing has been described as feasible and valued but limited by doctors, with pharmacists described as credible facilitators of prescribing feedback. Evidence supporting prescribing feedback has been limited to date. A formalised programme of pharmacist-led prescribing error feedback was designed and implemented to support prescribers.ObjectiveTo evaluate the impact of a prescribing feedback intervention on prescribing error rates and frequency of prescribing error severity and type.MethodProspective prescribing audits were undertaken across sixteen hospital wards in a UK teaching hospital over a five day period with 36 prescribers in the intervention group and 41 in the control group. The intervention group received pharmacist-led, individualised constructive feedback on their prescribing, whilst the control group continued with existing practice. Prescribing was re-audited after three months. Prescribing errors were classified by type and severity and data were analysed using relevant statistical tests.ResultsA total of 5191 prescribed medications were audited at baseline and 5122 post-intervention. There was a mean prescribing error rate of 25.0% (SD 16.8, 95% CI 19.3 to 30.7) at baseline and 6.7% (SD 9.0, 95% CI 3.7 to 9.8) post-intervention for the intervention group, and 19.7% (SD 14.5, 95% CI 15.2 to 24.3) at baseline and 25.1% (SD 17.0, 95% CI 19.8 to 30.6) post-intervention for the control group with a significant overall change in prescribing error rates between groups of 23.7% (SD 3.5, 95% CI, ?30.6 to ?16.8), t(75) = ?6.9, p < 0.05. The frequency of each error type and severity rating was reduced in the intervention group, whilst the error frequency of some error types and severity increased in the control group.ConclusionPharmacist-led prescribing feedback has the potential to reduce prescribing errors and improve prescribing outcomes and patient safety.     

Prevalence of inappropriate prescribing in primary care

Objective To describe the prevalence of inappropriate prescribing in primary care in Copenhagen County, according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved. Setting A cross-sectional study was conducted among 212 elderly ( >65 years) polypharmacy patients (five or more different medications) listed to 41 general practitioners (GPs) in the County of Copenhagen. Method Patients exposed to polypharmacy were identified via the database recording the drug subsidy system of Danish pharmacies. For each patient, data were collected on subsidised medications prescribed over 3 months by the patients’ own GPs. The GPs were asked to provide baseline information regarding the patients’ medical history and detailed information regarding the subsidised and non-subsidised medications prescribed to the patients. A MAI was scored for medication prescribed to the patients. Topical, dermatological medications and medications not used regularly were excluded. Results 212 patients were prescribed 1621 medications by their GPs at baseline. In all, 640 (39.5%) of the medications had one or more inappropriate ratings in the 10 criteria making up the MAI. The main part of the patients (94.3%) had one or more inappropriate ratings among their medications. A total of 12.3% of the medications were rated as ‘not indicated’, 6% were rated as ‘ineffective’, 6.7% were given in an incorrect dose, 0.7% were prescribed with incorrect directions, 1.3% had impractical directions, 0.7% of the drugs had clinically significant drug–drug interactions, 8.6% had clinically significant drug–disease/condition interactions, 3.1% were unnecessary duplications, 16.5% were given in an unacceptable duration and 27.1% of the medications were not the least expensive alternative. The therapeutic groups most commonly involved in inappropriate prescribing were medications for treatment of peptic ulcer, cardiovascular medications, anti-inflammatory medications, antidepressants, hypnotics and anti-asthmatics. Conclusion The overall prescribing quality in primary care in Copenhagen County, Denmark is good. However, the majority of patients used one or more medications with inappropriate ratings. The inappropriate prescribing relates to specific therapeutic groups and criteria, which should be targeted in future interventions.     

Differences in drug prescribing patterns in elderly parkinsonian patients identified at hospital admission.

In the period July 1984 to June 1993 a total of 4541 admissions to a Department of Medicine for the Elderly were investigated. Approximately 9% of the total were diagnosed to have parkinsonism. Full drug histories together with the available demographic and clinical data were investigated in order to identify differences in the prescribing patterns in this group compared to those of non–parkinsonian patients admitted during this time frame. There was a statistically significant lower incidence among the parkinsonian group for the prescribing of all cardiovascular drug groups, anticoagulants, hypoglycaemics, bronchodilators, and corticosteroids compared with non–parkinsonian patients. In contrast, the incidence of hypnotics, laxatives, antidepressants and antipsychotics were significantly higher.     

Quality of prescribing for schizophrenia: Evidence from a national audit in England and Wales

The National Audit of Schizophrenia (NAS) examined the quality of care received in England and Wales. Part of the audit set out to determine whether six prescribing standards, set by the national clinical guidelines for schizophrenia, were being implemented and to prompt improvements in care. Mental Health Trusts and Health Boards provided data obtained from case-notes for adult patients living in the community with schizophrenia or schizoaffective disorder. An audit of practice tool was developed for data collection. Most of the 5055 patients reviewed were receiving pharmacological treatment according to national guidelines. However, 15.9% of the total sample (95%CI: 14.9–16.9) were prescribed two or more antipsychotics concurrently and 10.1% of patients (95%CI: 9.3–10.9) were prescribed medication in excess of recommended limits. Overall 23.7% (95%CI: 22.5–24.8) of patients were receiving clozapine. However, there were many with treatment resistance who had no clear reason documented as to why they had not had a trial of clozapine (430/1073, 40.1%). In conclusion, whilst most people were prescribed medication in accordance with nationally agreed standards, there was considerable variation between service providers. Antipsychotic polypharmacy, high dose prescribing and clozapine underutilisation in treatment resistance were all key concerns which need to be further addressed.     

Treatment priorities and current prescribing patterns in hypertension: results of GRASP,an international physician survey

SUMMARY

The GRASP (Global Research on Attitudes about hypertension and Stroke Prevention) survey, conducted in 11 countries and involving 825 physicians, was designed to investigate physician perceptions and priorities in the treatment of hypertension and influences on choice of antihypertensive therapy. The prevention of stroke was identified as a major priority in this survey, but there appeared to be some degree of mismatch between the evidence from large controlled trials and current patterns of prescribing for stroke prevention. The results of GRASP confirm the desirability of research to identify methods and strategies that will facilitate the integration of clinical trial results into general practice treatment of hypertension.     

Practical prescribing with aripiprazole in schizophrenia: consensus recommendations of a UK multidisciplinary panel

ABSTRACT

Background: The atypical antipsychotic, aripiprazole, differs from other antipsychotics in its pharmacology and clinical outcomes. Aripiprazole's clinical outcomes include beneficial effects on mood, quality of life and cognition; favourable tolerability with low potential for sedation; and a favourable physical health profile, with low potential for weight change, sexual dysfunction or adverse metabolic effects. Such outcomes, particularly cognitive improvements, may allow for greater psychosocial intervention and improved social inclusion. In accordance with the UK NICE guidance on the use of antipsychotic treatment for schizophrenia (2002), aripiprazole may be an appropriate therapeutic option for patients with schizophrenia who are newly diagnosed, in acute relapse or experiencing tolerability problems, adverse metabolic effects or dissatisfaction with their current medication.

Scope: A multidisciplinary panel was convened in the UK in October 2006 to discuss and provide practical guidance regarding the potential benefits and risks of prescribing aripiprazole. This report describes the consensus recommendations agreed during the meeting and includes practical guidance on the optimal approach to prescribing aripiprazole, which patients might benefit from aripiprazole and how best to approach initiation of and switching to treatment with aripiprazole. A PubMed/MEDLINE literature search was conducted to support these recommendations.

Findings: To support antipsychotic therapy, a therapeutic partnership should be established between the patient and a well-informed, multidisciplinary care team. Aripiprazole should be initiated at the minimal efficacious dose (10?mg/day) and titrated as required (usually to 15?mg/day) after a minimum of 2 weeks. The primary goal during aripiprazole initiation is to ensure the patient completes the first few days of treatment, with support from concomitant medications if required. Nausea, insomnia and agitation may occur in 10–20% of patients, but are manageable and typically resolve during the first 3–7 days of therapy. The dose of any prior antipsychotic should remain stable until the response to aripiprazole is satisfactory and then the previous antipsychotic should be tapered off slowly over several weeks or more.

Conclusion: Patients are more likely to adhere to treatment with aripiprazole – and indeed any other antipsychotic – and derive long-term therapeutic benefits if they and a well-informed care team are involved in the treatment decision, establish a therapeutic partnership, are aware of the transient nature of any adverse events and understand what the potential long-term benefits are.