Prevention of medication errors: teaching and training

1. Poor prescribing is probably the most common cause of preventable medication errors in hospitals, and many of these events involve junior doctors who have recently graduated. Prescribing is a complex skill that depends on a sound knowledge of medicines, an understanding of the principles of clinical pharmacology, the ability to make judgements concerning risks and benefits, and ideally experience. It is not surprising that errors occur.
2. The challenge of being a prescriber is probably greater now than ever before. Medical education has changed radically in the last 20 years, reflecting concerns about an overburdened curriculum and lack of focus on social sciences. In the UK, these changes have resulted in less teaching in clinical pharmacology and practical prescribing as guaranteed features of undergraduate training and assessment. There has been growing concern, not least from students, that medical school training is not sufficient to prepare them for the pressures of becoming prescribers. Similar concerns are being expressed in other countries. While irrefutable evidence that these changes are related to medication errors identified in practice, there is circumstantial evidence that this is so.
3. Systems analysis of errors suggests that knowledge and training are relevant factors in causation and that focused education improves prescribing performance. We believe that there is already sufficient evidence to support a careful review of how students are trained to become prescribers and how these skills are fostered in the postgraduate years. We provide a list of guiding principles on which training might be based.     

How could undergraduate education prepare new graduates to be safer prescribers?

This review examines the extent to which undergraduate prescribing education prepares graduates for the complexities of prescribing in the workplace context. In order to prescribe safely, it is important for medical students to acquire prescribing expertise. We have developed a theoretical model, based on theories of expertise development, which acknowledges the inherent complexity of the task itself, the social context and the relationship between the two. We have examined the empirical evidence on educational interventions for prescribing by reviewing the extent to which the interventions acknowledge the different components of our theoretical model. Fifteen empirical studies met our inclusion criteria and were reviewed in detail. All the studies were conducted between 2002 and 2010, six were controlled trials, six were before and after studies and three were prospective observational studies. We found that most studies focused on improving and evaluating students' knowledge and skills, although they used different approaches to doing so. These aspects of prescribing only constitute a small part of our theoretical model of prescribing expertise. Other important components, such as social context, metacognition and training transfer, were neglected. We suggest that educational interventions need to account for the integrated nature of learning to prescribe and take a more contextualized approach which considers the task as a whole, rather than isolated constituent parts. In doing so, prescribing education could equip graduates with the necessary expertise to judge and respond to situations, enabling them to prescribe safely, or seek the help to do so, in the unpredictable and complex context of workplaces.     

Development of learning outcomes for an undergraduate prescribing curriculum (British Pharmacological Society prescribing initiative)

AIMS

The question of whether new medical graduates are adequately prepared for the challenge of prescribing has been raised. Although broad outcomes for prescribing competency have been agreed, clarity is needed on the detailed outcomes expected of new graduates. This study aimed to create a consensus on the required competencies for new graduates in the area of prescribing.

METHODS

We used a modified Delphi approach based on the findings of a systematic review of educational interventions for improved prescribing. Panellists were asked to rank the importance of a list of 53 possible learning outcomes and to add any additional outcomes felt to be missing.

RESULTS

Of the 48 experts who were invited to participate, 28 agreed (58%). Forty-five learning outcomes were included from the original list of 53. A further nine outcomes were suggested by panellists, of which five were included. The wording of three outcomes was changed in line with suggestions from the panellists. Many of the agreed outcomes relate to improving patient safety through medication review, checking appropriateness of the drug for the patient, recognizing the prescriber''s limitations and seeking advice when needed. Enhanced communication with the patient and healthcare team, better documentation in the notes and discharge letters were key areas featured in this Delphi exercise.

DISCUSSION

This study has identified 50 learning outcomes for teaching prescribing. These build on the existing British Pharmacological Society document by focusing specifically on prescribing, with greater emphasis on avoiding medication errors and better communication.     

Teaching clinical pharmacology and therapeutics with an emphasis on the therapeutic reasoning of undergraduate medical students

Background The rational prescribing of drugs is an essential skill of medical doctors. Clinical pharmacologists play an important role in the development of these skills by teaching clinical pharmacology and therapeutics (CP&T) to undergraduate medical students. Although the approaches to teaching CP&T have undergone many changes over the last decennia, it is essential that the actual teaching of CP&T continues to be a major part of the undergraduate medical curriculum. Objectives The learning objectives of CP&T teaching in terms of developing the therapeutic competencies of undergraduate medical students are described, with an emphasis on therapeutic decision-making. On the basis of current theories of cognitive psychology and medical education, context-learning is presented as an effective approach by which to achieve therapeutic competencies. An example of a CP&T curriculum is presented.     

Teaching rational prescribing: a new clinical pharmacology curriculum for medical schools

In most U.S. and Canadian medical schools, pharmacology is taught during the preclinical year 2 of the 4-year-long curriculum. This is despite the fact that medical school graduates and residency directors have identified teaching rational therapeutics as a priority. Hence, we have developed a core curriculum in clinical pharmacology for 4th-year medical students that builds on the core principles of rational therapeutics described by Nierenberg 10 years ago (Nierenberg, DW. Clin Pharmacol Ther 1990; 48:606-610). Here we report on our 3-year experience teaching this course, which addresses the following teaching objectives: to teach medical students on how to (1) critically evaluate medications; (2) obtain a complete medication history including herbal and over-the-counter medications; (3) apply pharmacokinetic principles to clinical practice; (4) recognize and report adverse drug events and interactions; (5) optimize pain management; (6) recognize and treat substance abuse and poisoning; and (7) prescribe rationally regardless of prescribing environment. Student assessment was in the form of multiple-choice and formative oral examinations, which were validated against the clinical part of the U.S. medical licensing examination. The course significantly increased the student rating of clinical pharmacology teaching measured by a national survey of U.S. medical school graduates. We conclude that this course may be useful for teaching rational prescribing to medical students. With the guidance and educational material provided by this article, a successful implementation of such a course should be possible in most medical schools.     

Construction and evaluation of a web-based interactive prescribing curriculum for senior medical students

AIMS: To develop and evaluate for the National Prescribing Service (NPS) a web-based interactive prescribing curriculum for Australian senior medical students based on the World Health Organization's Guide to Good Prescribing. METHODS: Teachers of prescribing from all Australian medical schools in 2000 wrote 12 case-based modules which were converted to on-line format. Objective evidence was provided for selecting first-line medicines from available alternatives by comparing efficacy, safety, convenience and cost. The curriculum was made available to final year students in 2001 and was evaluated by measuring use from web statistics and by semistructured interviews with 15 teachers (2003) and on-line surveys of 363 students over 2003 and 2004. RESULTS: By 2004 the curriculum was used by nine of 11 possible medical schools. Uptake increased each year from 2001 and all 12 modules were accessed consistently. Student access was significantly (P < 0.001) greater when prescribing was an assessable part of their course. Teachers' evaluations were uniformly supportive and the curriculum is seen as a valuable resource. Student responses came from a small proportion of those with password access but were also supportive. Over half of student respondents had created their own evidence-based formulary. CONCLUSIONS: A collaborative venture initiated by the NPS with Australian medical schools has been successfully implemented in most courses. Teachers find the resource of high quality. Student respondents find the curriculum valuable in developing their own prescribing skills. It is best delivered by self-directed study followed by tutorial discussion of prescribing decisions.     

Educating European (junior) doctors for safe prescribing

Evidence of poor prescribing is widespread including overuse of medicines, underuse of effective medicines, avoidable adverse drug reactions and medication errors. Junior doctors who have recently graduated are responsible for much of the prescribing that takes place in hospitals and are implicated in many of the adverse medication events. Analysis of such events suggests that lack of knowledge and training underlies many of them and it has been shown that dedicated training can increase prescribing performance. In the context of these problems, it is a matter of increasing concern that recent changes to undergraduate medical education may have reduced exposure to clinical pharmacology, a discipline dedicated to optimal practice in relation to medicines. For this reason, the European Association of Clinical Pharmacology and Therapeutics (EACPT) and British Pharmacological Society (BPS) jointly organized a meeting to explore (i) the state of undergraduate education in clinical pharmacology in Europe, (ii) the knowledge and competencies in relation to medicines that should be expected of a new graduate, (iii) assessments that might demonstrate that this minimum standard had been reached, (iv) a curriculum that might help medical students to achieve this standard and (v) how competence can be developed in the postgraduate phase. It was agreed that the lack of exposure to clinical pharmacology is a cause for concern at a time when the challenges facing junior prescribers have never been greater. The potential for undertaking further research was discussed.     

Instruction in clinical pharmacology: changes in the wind

We have presented some views on past, present and potential trends for teaching clinical pharmacology in the medical curriculum. Clinical pharmacology as subject matter in the medical curriculum has been operationally defined for our purposes as: (1) the application of fundamental principles of basic pharmacology to rational drug therapy in humans; and (2) the application of appropriate nuances of the human pharmacology of individual drugs to their use in particular disease states. In terms of improving the results of drug therapy, arguments were advanced for the importance of teaching clinical pharmacology at all levels in the medical curriculum and in postgraduate medical education. The introduction of so many new and potent pharmaceuticals over the past 25 years requires well educated and skilled medical practitioners adept and well versed in the fundamental principles of basic and applied pharmacology, so as to achieve the most prudent, effective and economically sound use of these drugs as possible. This creates a challenge to medical educators, particularly those involved in teaching clinical pharmacology, to devise innovative teaching techniques and curricular changes that foster these goals. In an attempt to address these challenges, we have reviewed some innovative teaching approaches and curricular reforms, both published and unpublished, that have already met with success, and we have also discussed some future trends in teaching both undergraduate and graduate physicians the fundamental principles of rational drug therapy. The challenges and issues involved in these future trends have been identified and will be addressed in subsequent articles in this journal. These will be concerned with teaching clinical pharmacology: (1) in basic medical pharmacology courses; (2) to upperclass medical students; and (3) in continuing medical education programs. Subsequent articles will also deal with new and innovative teaching modalities for clinical pharmacology and with the role of the drug industry in these modalities.     

Teaching of pharmacology in Universiti Malaya and the other medical schools in Malaysia -- a historical perspective

Traditional pharmacology teaching has focused more on drug instead of therapeutics, such that although pharmacological knowledge is acquired, practical skills in prescribing remain weak. In Malaysia many new medical schools (both public and private) have been set up in the last 12 years due to a change in government policy, resulting in a wide spectrum of medical curricula. Universiti Malaya (UM) being the oldest medical school in Malaysia was deep set in its traditional way of teaching-learning, since its inception in 1962, until a visit from the General Medical Council of the United Kingdom in 1984 triggered off a change of tide. Since then the medical curriculum in UM has undergone two major revisions. The first revised curriculum (1988) aimed to inject more clinical relevance into basic science teaching, through introducing clinical lectures and skills in the paraclinical year. Professional behaviour was also addressed. The second revised curriculum (1998) sought to improve further the integration of knowledge as well as to produce a holistic doctor, viewing the patient as a person instead of a clinical entity. The teaching-learning of pharmacology has gradually moved from factual regurgitation to more clinical reasoning, from lab-based to more patient-oriented approach. As more new medical schools are being set up in Malaysia, exchange of experience in this area of learning will hopefully help us find a happy medium between “the old is best” and “the new is better” type approach so that a pedagogically sound and yet logistically practical curriculum can be found in our local setting, to help produce doctors with good prescribing practice.     

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.     

Implementation of the WHO-6-step method in the medical curriculum to improve pharmacology knowledge and pharmacotherapy skills

Aim

The only validated tool for pharmacotherapy education for medical students is the 6-step method of the World Health Organization. It has proven effective in experimental studies with short term interventions. The generalizability of this effect after implementation in a contextual-rich medical curriculum was investigated.

Methods

The pharmacology knowledge and pharmacotherapy skills of cohorts of students, from years before, during and after implementation of a WHO-6-step-based integrated learning programme were tested using a standardized assessment containing 50 items covering knowledge of basic (n = 25) and clinical (n = 24) pharmacology, and pharmacotherapy skills (n = 1 open question). All scores are expressed as a percentage of the maximum score possible per (sub)domain.

Results

In total, 1652 students were included between September 2010 and July 2014 (participation rate 89%). The WHO-6-step-based learning programme improved students’ knowledge of basic pharmacology (mean score ± SD, 60.6 ± 10.5% vs. 63.4 ± 10.9%, P < 0.01) and clinical or applied pharmacology (63.7 ± 10.4% vs. 67.4 ± 10.3%, P < 0.01), and improved their pharmacotherapy skills (68.8 ± 26.1% vs. 74.6% ± 22.9%, P 0.02). Moreover, satisfaction with education increased (5.7 ± 1.3 vs. 6.3 ± 1.0 on a 10-point scale, P < 0.01) and as did students’ confidence in daily practice (from −0.81 ± 0.72 to −0.50 ± 0.79 on a −2 to +2 scale, P < 0.01).

Conclusions

The WHO-6-step method was successfully implemented in a medical curriculum. In this observational study, the integrated learning programme had positive effects on students’ knowledge of basic and applied pharmacology, improved their pharmacotherapy skills, and increased satisfaction with education and self-confidence in prescribing. Whether this training method leads to better patient care remains to be established.     

Bridging the gap: improving safe prescribing from university to workplace

One of the challenges for Foundation Year 1 junior doctors is to apply the theoretical pharmacology from their undergraduate years into practical prescribing. The EQUIP study in 2009 investigated the causes of prescribing errors by junior doctors. Respondents in the study reported deficiencies in their education for prescribing skills and error prevention. The study suggested more could be done during undergraduate education to link theory with practice. This article describes an initiative from a hospital clinical pharmacy team to address this gap in contextual prescribing skills. Final year medical students (FY0s) were allocated to the Belfast Trust for an 11 week placement. The Clinical Pharmacy team developed a 3 h FY0 workshop focusing on practical prescribing scenarios identified as high risk by local medicines safety teams. The workshops included simulated case studies requiring the FY0 student to discuss medicine use with patients, prescribe admission drug charts and use local guidelines to safely prescribe high risk medicines. Each student was assessed using direct observation of procedural skills (DOPS). Feedback was overwhelmingly positive. Students appreciated the practical elements of the workshop. Initially there was an over-reliance on written medication history without verbally engaging the patient. Following pharmacist feedback before the DOPS students demonstrated a clear improvement in patient communication. Feedback from the FY0 students also identified additional learning needs that formed the basis of further teaching.     

Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow's doctors

There is a pressing need for medical graduates to be fully prepared to take on the responsibilities of prescribing and to be able to respond to continual inevitable rapid changes in therapeutics. The curricula in UK medical schools were greatly influenced by Tomorrow's Doctors, published by the General Medical Council in 1993. This has recently been updated. While it highlights the management of disease and use of drugs as key learning objectives, it offers little specific guidance. In this document we expand on these broad statements, provide a view of how these learning objectives might be achieved, and identify the key elements of a core curriculum in prescribing and therapeutics.     

对临床医学专业开设《麻醉学》课程的认识及教学计划构想

医科大学培养的学生应该拓宽知识面,具有内科学、外科学、妇产科学、儿科学、麻醉学等综合技能,以适应社会发展的需要。在临床医学本科生中开设《麻醉学》课程可以提高麻醉学科水平;使得麻醉学科成为真正意义上的二级学科、临床一级科室;是医学教育服从社会并满足社会需要的必然。