Article Commentary: Of snarks, boojums and national drug charts

Abstract

Lewis Caroll's ‘The Hunting of the Snark’ – subtitled ‘An Agony in Eight Fits’ – was a nonsense poem. Its use in the title of this essay1 is, in itself, very fitting. The objections to a national drug chart, made by Barber et al.1 in this issue of the JRSM, lack credibility. First, there is substantial evidence from the Australia, that a National Drugs Chart can reduce errors. Barber et al.1 have misinterpreted the study by Coombes et al.2, showing a reduction in prescribing errors, by adopting a National Drugs Chart. Whether some of the error reduction was due to an improved prescription form is hardly a reason for challenging its overall generalizability. On the contrary, it demonstrates what can be achieved. Moreover, Coombes et al.2 not only showed a substantial reduction in overall prescribing errors but also reduced rates in each of 11 out of 12 individual types of error. For example, re-prescription of drugs to which patients had previously had an adverse reaction to a product in the same class, fell by over 50%. And there was a significant decrease in the potential risks associated with warfarin therapy. Secondly Barber et al.1 believe that undergraduate and postgraduate medical and nursing student need more, and better, education on the use of Drug Charts. I am sure they are right. But ensuring the availability of adequate training materials, across every National Health survey (NHS) Trust each with its own Drug Chart, is fanciful and unnecessary. Much better to draw up a National Drug Chart, with associated training materials, available to all. Thirdly, a National Drugs Chart, together with an online training package can be delivered and accepted in a UK environment.3 The claim that, because Wales is relatively small and homogeneous, it is a poor example for England is disingenuous. We, in England, should be prepared to adopt good practice that leads to an improved quality care, irrespective of its provenance. Fourthly Barber et al.1 claim that it is fallacious to think one chart is sufficient. Of course it is not enough. Eventually we need to standardize all of our hospital charts but – in the meantime – let us get the most widely used one sorted out. Barber et al.1 also seem to believe that local charts are needed to meet local CQUIN targets. That is sheer nonsense and indicates a lack of understanding about the various schemes now in place to encourage high quality of care. Finally the argument that, because electronic prescribing is increasingly prevalent in UK hospitals, standardized drug charts will soon be defunct is yet more nonsense. Only a minority of hospitals have e-prescribing available for inpatients; and it will be years before this is common across the NHS. In the meantime we should stop messing around and introduce a National Drugs Chart – for inpatients – and have done with it. It is curious that, at a time when hospital doctors who prescribe drugs and nurses who administer them, are all clamouring for a National Drugs Chart, it is opposed by a coterie of pharmacists. The Royal College of Physicians of London have developed a National Drugs Chart and are asking their fellows to press for its introduction in their own NHS institutions in England. I hope that their local hospital pharmacists back them.