Providing feedback to hospital doctors about prescribing errors; a pilot study

Abstract

Objective To assess the feasibility and acceptability of obtaining data on prescribing error rates in routine practice, and presenting feedback on such errors to medical staff. Setting One clinical directorate of a London teaching trust. Methods Ward pharmacists recorded all prescribing errors identified in newly written medication orders on one day each fortnight between February and May 2005. We examined prescribing errors reported on the trust's medication incident database for the same period. Main outcome measures Prescribing errors identified and recorded by ward pharmacists, prescribing errors reported as incident reports; prescribing error rates per clinical specialty; lead consultants' views on receiving feedback on errors for their specialty. Results During eight data collection days, 4,995 new medication orders were examined. Of these, 462 (9.2%; 95% confidence interval 8.5 -10.1%) contained at least one prescribing error. There were 474 errors in total. Pharmacists indicated that they would have reported 19 (4%) of the prescribing errors as medication incidents. Eight prescribing errors were reported for the entire four-month study period on non-data collection days. Feedback was presented to lead clinicians of 10 clinical specialties. This included graphical summaries showing how the specialty compared with others, and a list of errors identified. This information was well-received by clinicians. Conclusion Prescribing errors identified by ward pharmacists can be systematically fed back at the level of the clinical specialty; this is acceptable to the consultants involved. Incident report data is subject to gross under-reporting. Routinely providing feedback for each consultant team or for individual prescribers will require more focussed data collection.Keywords Hospital Á Incident reports Á Medication errors Á Pharmacists Á Prescribing errors Á United Kingdom What this study adds• We developed a method for summarising prescribing error data for presentation to clinical specialties.• Lead clinicians found this feedback to be useful and acceptable.• Ward pharmacists identified prescribing errors in 9.2% of newly written medication orders in one clinical directorate.• Incident report data is subject to gross underreporting and is not useful in providing quantitative estimates of error rates.

Safe prescribing by junior doctors

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Including pharmacists on consultant-led ward rounds: a prospective non-randomised controlled trial

“…Different physicians may make different prescribing errors. However, previous work suggests that there are no obvious differences in prescribing error rates between clinical specialties 19 and it is believed that this is unlikely to have affected the study's conclusions.…”

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