Pilot of a National Inpatient Medication Chart in Australia: improving prescribing safety and enabling prescribing training

AIMS

To establish whether a standard national inpatient medication chart (NIMC) could be implemented across a range of sites in Australia and reduce frequency of prescribing errors and improve the completion of adverse drug reaction (ADR) and warfarin documentation.

METHODS

A medication chart, which had previously been implemented in one state, was piloted in 22 public hospitals across Australia. Prospective before and after observational audits of prescribing errors were undertaken by trained nurse and pharmacist teams. The introduction of the chart was accompanied by local education of prescribers and presentation of baseline audit findings.

RESULTS

After the introduction of the NIMC, prescribing errors decreased by almost one-third, from 6383 errors in 15 557 orders, a median (range) of 3 (0–48) per patient to 4293 in 15 416 orders, 2 (0–45) per patient (Wilcoxon Rank Sum test, P < 0.001). The documentation of drugs causing previous ADRs increased significantly from 81.9% to 88.9% of drugs (χ² test, P < 0.001). The documentation of the indication for warfarin increased from 12.1 to 34.3% (χ² test, P = 0.001) and the documentation of target INR increased from 10.8 to 70.0% (χ² test, P < 0.001) after implementation of the chart.

CONCLUSIONS

National implementation of a standard medication chart is possible. Similar reduction in the rate of prescribing errors can be achieved in multiple sites across one country. The consequent benefits for patient care and training of staff could be significant.     

e-Learning initiatives to support prescribing

Preparing medical students to prescribe is a major challenge of undergraduate education. They must develop an understanding of clinical pharmacology and acquire knowledge about drugs and therapeutics, as well as the skills to prescribe for individual patients in the face of multiple variables. The task of delivering the learning required to achieve these attributes relies upon limited numbers of teachers, who have increasingly busy clinical commitments. There is evidence that training is currently insufficient to meet the demands of the workplace. e-Learning provides an opportunity to improve the learning experience. The advantages for teachers are improved distribution of learning content, ease of update, standardization and tracking of learner activities. The advantages for learners are ease of access, greater interactivity and individual choice concerning the pace and mix of learning. Important disadvantages are the considerable resource required to develop e-Learning projects and difficulties in simulating some aspects of the real world prescribing experience. Pre-requisites for developing an e-Learning programme to support prescribing include academic expertise, institutional support, learning technology services and an effective virtual learning environment. e-Learning content might range from complex interactive learning sessions through to static web pages with links. It is now possible to simulate and provide feedback on prescribing decisions and this will improve with advances in virtual reality. Other content might include a student formulary, self-assessment exercises (e.g. calculations), a glossary and an on-line library. There is some evidence for the effectiveness of e-Learning but better research is required into its potential impact on prescribing.     

基于指纹识别的电子签名在门诊电子处方系统的初步应用

目的:利用生物指纹识别技术与数字化加密技术,对传统手写签名进行转化,形成电子签名,探讨其安全性与唯一性,井初步运用于门诊电子处方系统.方法:通过采集医生的纸质手写签名,经过高分辨率扫描后制作统一格式的电子签章,同时采集医生本人生物指纹与之关联,通过特定数字化转换并加密置于后台验证服务器形成电子签名,用于在电子处方提交保存时核对、调用该医生的电子签名.结果:该电子签名认证系统成功运用于我院电子处方系统,指纹认证过程准确迅速,处方的完整性、有效性、唯一性得到提高,整个系统运行稳定.结论:基于生物指纹识别的电子签名技术能够保证处方的真实,陸与完整性,优化工作流程.提高工作效率,通过无纸化节约经费.     

Junior doctors' perceptions of their self-efficacy in prescribing,their prescribing errors and the possible causes of errors

Aims

The aim of the study was to explore and compare junior doctors'' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of those errors.

Methods

A cross-sectional questionnaire study was distributed to foundation doctors throughout Scotland, based on Bandura''s Social Cognitive Theory and Human Error Theory (HET).

Results

Five hundred and forty-eight questionnaires were completed (35.0% of the national cohort). F1s estimated a higher daytime error rate [median 6.7 (IQR 2–12.4)] than F2s [4.0 IQR (0–10) (P = 0.002)], calculated based on the total number of medicines prescribed. The majority of self-reported errors (250, 49.2%) resulted from unintentional actions. Interruptions and pressure from other staff were commonly cited causes of errors. F1s were more likely to report insufficient prescribing skills as a potential cause of error than F2s (P = 0.002). The prescribers did not believe that the outcomes of their errors were serious. F2s reported higher self-efficacy scores than F1s in most aspects of prescribing (P < 0.001).

Conclusion

Foundation doctors were aware of their prescribing errors, yet were confident in their prescribing skills and apparently complacent about the potential consequences of prescribing errors. Error causation is multi-factorial often due to environmental factors, but with lack of knowledge also contributing. Therefore interventions are needed at all levels, including environmental changes, improving knowledge, providing feedback and changing attitudes towards the role of prescribing as a major influence on patient outcome.     

The epidemiology of medication errors: how many,how serious?

1. Errors will always occur in any system, but it is essential to identify causes and attempt to minimize risks.
2. Although it is difficult to quantify precisely the extent of medication errors, they are clearly frequent and often avoidable, representing a major threat to patient safety.
3. Many of the consequences of these errors can be prevented by the intervention of pharmacists.
4. Some errors are due to the conditions under which prescribers work; where possible these should be improved (for example, low staffing levels).
5. Computerized prescribing can help but can also generate its own inherent errors.
6. Improved training of prescribers at the undergraduate and postgraduate levels is vital, a fact that is now being belatedly recognized.     

利用电子处方信息分析门诊医师处方行为

目的研究电子处方信息在门诊医师处方行为分析中的应用。方法采集某区级中心医院消化内科2010年全年疾病诊断为消化道溃疡的电子处方信息进行分析,运用SPSS18.0进行统计检验和分析。结果中级职称的医师处方总金额和处方中国产药品金额与初、高级职称相比存在显著性差异,自费患者的处方总金额、处方品种总数和国产药品金额均高于医保患者,处方总金额与患者费别、患者年龄段、处方中进口药品品种构成比、处方中自费药品品种构成比和金额构成比存在线性相关。结论中级职称医师应当是该院门诊药品消费控制干预的重点人群,医保政策无法干预医师对自费药品的处方行为,电子处方信息可结合疾病诊治规范解释处方行为差异。     

Safe prescribing: a titanic challenge

The challenge to achieve safe prescribing merits the adjective 'titanic'. The organisational and human errors leading to poor prescribing (e.g. underprescribing, overprescribing, misprescribing or medication errors) have parallels in the organisational and human errors that led to the loss of the Titanic 100 years ago this year. Prescribing can be adversely affected by communication failures, critical conditions, complacency, corner cutting, callowness and a lack of courage of conviction, all of which were also factors leading to the Titanic tragedy. These issues need to be addressed by a commitment to excellence, the final component of the 'Seven C's'. Optimal prescribing is dependent upon close communication and collaborative working between highly trained health professionals, whose role is to ensure maximum clinical effectiveness, whilst also protecting their patients from avoidable harm. Since humans are prone to error, and the environments in which they work are imperfect, it is not surprising that medication errors are common, occurring more often during the prescribing stage than during dispensing or administration. A commitment to excellence in prescribing includes a continued focus on lifelong learning (including interprofessional learning) in pharmacology and therapeutics. This should be accompanied by improvements in the clinical working environment of prescribers, and the encouragement of a strong safety culture (including reporting of adverse incidents as well as suspected adverse drug reactions whenever appropriate). Finally, members of the clinical team must be prepared to challenge each other, when necessary, to ensure that prescribing combines the highest likelihood of benefit with the lowest potential for harm.     

The potential role of computerisation and information technology in improving prescribing in hospitals

For physicians, prescribing of drugs is one of the most common actions in daily practice. In the continuum prescribing, dispensing, administration and use of drugs, failures may occur and can lead to patient harm. The use of computerised physician order entry systems is subject to much discussion regarding medication error reduction. This commentary analyses the issues where such systems can contribute to improved care.