The Prescribing Improvement Model

Example from Imperial College Healthcare NHS TrustPublished
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Summary

Summary of the example

The Prescribing Improvement Model consists of a three-part intervention:

1. Increasing the proportion of handwritten inpatient medication orders where the prescriber specifies their name, allowing prescriber identification – through the provision of name stamps, modification of drug charts if needed, educational interventions and regular audits;

2. Provision of training for pharmacists to improve the quality, consistency and frequency of one-to-one feedback on prescribers’ errors – led by hospital pharmacy education leads and clinical pharmacists, based on educational and psychological theories around feedback and co-created with junior medical staff;

3. Facilitating shared learning from common and/or serious errors among pharmacists and doctors within each organisation, via a ‘good prescribing tip of the fortnight’ sent by email co-created with junior medical staff – led by medication safety officers and/or pharmacy education leads.

The core components are parts (2) and (3); part (1) is not generally applicable to organisations using electronic prescribing. Part (3) can be adapted to fit local contexts – for example if an organisation has a regular training session for junior doctors, the ‘good prescribing tip of the fortnight’ could be presented here as well as, or instead of, being sent via email. The frequency and content of the prescribing tips can also be modified to fit local context.

Why we think it’s important

Prescribing medication is the most common healthcare intervention, with most hospital inpatients prescribed medication during their stay. However, errors are common and studies indicate that prescribing errors are most likely to result in harm. UK studies suggest that these occur in 1-15% of inpatient medication orders with 1 in 100 inpatients harmed. Even prescribing errors that do not result in patient harm can result in anxiety among patients and carers, as well as rework by healthcare professionals.

Previous research highlighted in particular that hospital prescribers receive little feedback about their errors and are therefore unable to learn from them; a further barrier with paper-based prescribing is that individual prescribers often cannot be identified from their prescriptions and so feedback cannot be given. We therefore developed this model using quality improvement methodology, aiming to improve prescriber identification and error feedback. The ‘change theory’ was that provision of feedback on prescribing errors would facilitate learning, reflection and changes to practice, and thus increase safety of prescribing in the hospital setting. An evaluation revealed the percentage of medication orders for which junior doctors stated their name increased from about 10% to 50%, with improvements in pharmacists’ perceptions around feedback and doctors’ engagement with safe prescribing.

Learn more about the example

Aims and objectives of the work

Our objectives were to improve prescriber identification on medication orders in order to facilitate individual feedback and to provide effective feedback to prescribers at both the individual level and group level with the aim of reducing prescribing errors.

Methodology

We developed three linked interventions using plan–do–study–act cycles:

(1) name stamps for junior doctors who were encouraged to stamp or write their name clearly when prescribing

(2) principles of effective feedback to support pharmacists to provide
feedback to doctors on individual prescribing errors

(3) fortnightly prescribing advice emails that addressed a common and/or serious error.

Implementation and evaluation Interventions were introduced at one hospital site in August 2013 with a second acting as control. Process measures included the percentage of inpatient medication orders for which junior doctors stated their name. Outcome measures were junior doctors’ and pharmacists’ perceptions of current feedback provision (evaluated using quantitative pre-questionnaires and post-questionnaires and qualitative focus groups) and the prevalence of erroneous medication orders written by junior doctors between August and December 2013.

Key findings

The percentage of medication orders for which junior doctors stated their name increased from about 10% to 50%. Questionnaire responses revealed a significant improvement in pharmacists’ perceptions but no significant change for doctors.

Focus group findings suggested increased doctor engagement with safe prescribing. Interrupted time series analysis showed that the overall effect of intervention implementation (ie, the unique effect associated with the intervention while holding baseline trend and control constant) was a non-significant reduction in the error rate of 4% (β=−4.045; t=−0.638; p=0.532). Similarly the estimated trend in error rate was a non-significant decrease of 4% post-intervention (β=−4.440; t=−1.097; p=0.288).

The findings suggest improved experiences around feedback. However, attempts to produce a measurable reduction in prescribing errors are likely to need a multifaceted approach of which feedback should form part. It is also important to acknowledge the challenges of measuring error rates in a sufficiently sensitive manner within existing resources.

Positive unintended consequences were an increased quality of documentation in medical notes, with doctors also using name stamps here. No negative unintended consequences were identified.

The model was subsequently rolled out to some other hospitals in North West London with support of the local AHSN.

Documents

Video and toolkit available via the link below:

Links

Background

National guidance, data and publications

Published paper:

Reynolds M, Jheeta J, Sanghera I, Jacklin A, Ingle D, Franklin BD (2017). Improving feedback on junior doctors’ prescribing errors: mixed methods evaluation of a quality improvement project.

BMJ Quality and Safety;26:240-247

Open access paper  -see link below:

Links