Abstract

Background Prescribing errors are common, occurring in 7% of in-patient medication orders in UK hospitals. Foundation Year 1 (F1) doctors have reported a lack of feedback on prescribing as a cause of errors. Aim To evaluate the effect of implementing a shared learning intervention to Foundation Year 1 doctors on their prescribing errors. Methods A shared learning intervention, ‘good prescribing tip’ emails, were designed and sent fortnightly to F1s to share feedback about common/serious prescribing errors occurring in the hospital. Ward pharmacists identified prescribing errors in newly prescribed in-patient and discharge medication orders for 2 weeks pre- and post-intervention during Winter/Spring 2017. The prevalence of prescribing errors was compared pre- and post-intervention using statistical analysis. Results Overall, there was a statistically significant reduction ( p < 0.05) in the prescribing error rate between pre-intervention (441 errors in 6190 prescriptions, 7.1%) and post-intervention (245 errors in 4866 prescriptions, 5.0%). When data were analysed by ward type there was a statistically significant reduction in the prescribing error rate on medical wards (6.8% to 4.5%) and on surgical wards (8.4% to 6.2%). Conclusions It is possible to design and implement a shared learning intervention, the ‘good prescribing tip’ email. Findings suggest that this intervention contributed to a reduction in the prevalence of prescribing errors across all wards, thereby improving patient safety.

Highlights

  • Patient safety is a priority for the NHS and healthcare systems worldwide.[1]

  • Analysis of the data by ward type indicated a difference in error rates between Medicine and Surgery but in both, there was a statistically significant reduction following the intervention (Table 1)

  • 347 prescribing errors were identified in 5082 prescriptions pre-intervention (6.8%), and post-intervention 162 errors were identified in 3537 prescriptions (4.6%)

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Summary

Introduction

Patient safety is a priority for the NHS and healthcare systems worldwide.[1]. Reducing medication errors is a key improvement required for the NHS and to meet this challenge healthcare professionals must identify and implement changes to their practice.[2]Medication incidents are the fourth most reported type of incident reported to NHS improvement.[3]. Prescribing errors are common, occurring in 7% of in-patient medication orders in UK hospitals. Aim: To evaluate the effect of implementing a shared learning intervention to Foundation Year 1 doctors on their prescribing errors. Methods: A shared learning intervention, ‘good prescribing tip’ emails, were designed and sent fortnightly to F1s to share feedback about common/serious prescribing errors occurring in the hospital. Conclusions: It is possible to design and implement a shared learning intervention, the ‘good prescribing tip’ email. Findings suggest that this intervention contributed to a reduction in the prevalence of prescribing errors across all wards, thereby improving patient safety

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