Inpatient Prescription Charts Research Articles

The Smarter Sleep educational interventions: an initiative to reduce hypnotic prescribing in in-patient psychiatric care.

In-patients on mental health wards are commonly prescribed hypnotics for the long-term management of disturbed sleep. Specific sleep disorders remain underdiagnosed and effective behavioural interventions are underused. We developed a suite of three educational interventions (a video, poster and handbook) about sleep, sleep disorders, the safe prescribing of hypnotics and use of psychological strategies (sleep hygiene and cognitive-behavioural therapy for insomnia, CBTi) using co-design and multiprofessional stakeholder involvement. This controlled before-and-after study evaluated the effectiveness of these interventions across seven in-patient psychiatric wards, examining their impact on hypnotic prescribing rates and staff confidence scores (data collected by retrospective drug chart analysis and survey respectively). A marked reduction was seen in the percentage of patients prescribed hypnotics on in-patient prescription charts (-24%), with a 41% reduction in the number of hypnotics administered per patient (mean reduction -1.142 administrations/patient). These simple educational strategies about the causes and treatment of insomnia can reduce hypnotic prescribing rates and increase staff confidence in both the medical and psychological management of insomnia.

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: A multi-centre study.

Limited evidence concerning the burden and predictors of omitted medication doses within mental health hospitals could severely limit improvement efforts in this specialist setting. This study aimed to determine the prevalence, nature and predictors of omitted medication doses affecting hospital inpatients in two English National Health Service (NHS) mental health trusts. Over 6 data collection days trained pharmacy teams screened inpatient prescription charts for scheduled and omitted medication doses within 27 adult and elderly wards across 9 psychiatric hospitals. Data were collected for inpatients admitted up to two weeks prior to each data collection day. Omitted doses were classified as 'time critical' and 'preventable' based on established criteria. Omitted dose frequencies were presented with 95% confidence intervals (CI). Multilevel logistic regression analyses determined the predictors of omitted dose occurrence, with omission risks presented as adjusted odds ratios (OR) with 95% CI. 18,664 scheduled medication doses were screened for 444 inpatients and 2,717 omissions were identified, resulting in a rate of 14.6% (95% CI 14.1-15.1). The rate of 'time critical' omitted doses was 19.3% (95% CI 16.3-22.6%). 'Preventable' omitted doses comprised one third of all omissions (34.5%, 930/2694). Logistic regression analysis revealed that medicines affecting the central nervous system were 55% less likely to be omitted compared to all other medication classes (9.9% vs. 18.8%, OR 0.45 (0.40-0.52)) and that scheduled doses administered using non-oral routes were more likely to be omitted compared the oral route (inhaled OR 3.47 (2.64-4.57), topical 2.71 (2.11-3.46), 'other' 2.15 (1.19-3.90)). 'Preventable' dose omissions were more than twice as likely to occur for 'time critical' medications than non-time critical medications (50.4% vs. 33.8%, OR 2.24 (1.22-4.11)). Omitted medication doses occur commonly in mental health hospitals with 'preventable' omissions a key contributor to this burden. Important targets for remedial intervention have been identified.

Inpatient prescription charts on medical wards for older people – room for improvement?

The aim of the study was to determine adherence to Mid- Yorkshire Hospitals NHS Trust inpatient prescribing standards while implementing change and education in written prescribing to promote safe prescribing and patient safety. The retrospective audit was undertaken at Pinderfields General

Improving community prescribing of post-fracture denosumab after discharge.

In the UK, denosumab is usually started by hospital clinicians and continued by primary care physicians in the community, but in the authors' region denosumab is a 'green light' drug, only prescribed by the primary care team. The authors suspected that a proportion of patients who were recommended to start the drug after a neck of femur fracture were not receiving this on discharge. They aimed to improve the prescribing of denosumab by implementing a quality improvement project. A retrospective review of electronic records and case notes in primary and secondary care was undertaken, focusing on patients who were admitted with a neck of femur fracture and recommended denosumab. Following cycle 1 of the project two interventions were implemented: Denosumab written on the inpatient prescription chart at point of treatment decision, promoting inclusion in the discharge summary A consultant letter recommending denosumab was sent separately to primary care, in addition to inclusion in the discharge summary. Following these interventions this project cycle was repeated. A total of 91 patients with a neck of femur fracture were identified during cycle 1 and 22/91 (24%) were recommended denosumab. However, only five of these 22 patients (22%) received the drug. Following the interventions 23/26 eligible patients (88%) were prescribed denosumab (three patients did not have a prescription with no reason given), and 17/23 (74%) had the injection given. Four patients who did not receive the denosumab injection had no obvious reason for not starting treatment. In the other two patients, one discharge summary misleadingly stated that the injection had been given as an inpatient and one patient had recurrent admissions following discharge after their neck of femur fracture so primary care had not had any opportunity to administer the injection. Prescribing denosumab on the inpatient drug chart and highlighting its use in a consultant-written letter to the primary care team improved prescribing and administering of denosumab in the community.

Inpatient prescribing systems used in NHS Acute Trusts across England: a managerial perspective

ObjectiveThe individualised patient prescription chart, either paper or electronic, is an integral part of communication between healthcare professionals. The aim of this study is to ascertain the extent to which...

G538(P) Reducing prescribing errors by introducing a paediatric prescribing web-based learning module in a tertiary children’s hospital

Background Medication errors are a significant problem in theUK, and have the potential to cause harm. Children are particularly vulnerable. Errors occur at different decision-making points in the medicines pathway, and prescribing errors constitute a significant but potentially modifiable step in this process, which we targeted. Our hospital regularly audits prescribing against our local prescribing policy (the gold standard), which is based upon GMC guidance for safe prescribing. The rate of prescription error was 67% in 2010. We defined ‘prescription error’ as any deviation from the gold standard. From August 2010, our mandatory junior doctor induction was modified to include a 2 h lecture on paediatric prescribing (delivered by pharmacist and doctor) and a paediatric prescribing test. This combination was shown to reduce prescribing errors from 67% to 52%, and reduce incorrect or absent allergy information on prescription charts from 36% to 15% in 2010 and 2012 respectively. The problem Although effective in improving prescribing, the lecture had a large volume of information to deliver in a limited time. Administering and marking the test was time consuming and providing individual feedback was logistically challenging. A potential solution Web-based learning modules (WBLM) are accessible, low cost and can facilitate simultaneous education and assessment. Aim To design and pilot a WBLM to replicate the previous content of prescribing induction. The long-term aim is to continue to improve paediatric prescribing within our hospital. Primary objective Assess feasibility of introducing a WBLM as part of paediatric induction. Secondary objective Assess the effect of the WBLM on prescribing practice. The intervention The WBLM was designed by paediatricians (the authors) working with a Learnpro designer. It can be accessed remotely and is PC or tablet compatible. There are 3 main sections. The first is an introduction to paediatric prescribing, revising pharmacokinetics and local policy for safe prescribing. The second section uses clinical cases to illustrate prescribing challenges and focuses on areas where errors frequently occur. Adverse drug reactions, antibiotic monitoring, medication error reporting and discharge prescriptions are covered. The final section focuses on intravenous fluids. All sections contain links to relevant local clinical guidelines. Summative assessment questions are incorporated into the module, requiring trainees to obtain the correct answer before progressing. Implementation The WBLM was designed in early 2014. Usability was tested in a small group prior to a pilot in August 2014 for junior medical and surgical doctors attending hospital induction. Measurement of Improvement The Plan-Do-Study-Act cycle (PDSA) provides a structure for iterative testing of changes to improve quality. We are currently in the third cycle following the August 2014 pilot. All post-completion evaluations were positive. Minor technical issues reported have been addressed. The small scale testing has allowed adaptation according to feedback received. All inpatient prescription charts, excluding PICU who use electronic prescribing, were audited in November 2014 (Figure 1). There were 78 prescription charts containing 904 individual prescriptions. 85% of ‘regular’ prescriptions were prescribed correctly. Although only 68% of total prescriptions were correct, a significant proportion of errors were in ‘once only’ and ‘PRN’ sections, commonly completed in A+E by doctors, who had not undertaken the WBLM. From 2015 the WBLM will be mandatory for all trainees rotating through the hospital, including A+E, anaesthesia and PICU. Conclusion It is feasible to implement a WBLM as part of paediatric prescribing induction. Extending implementation to all hospital departments has the potential to be effective in improving paediatric prescribing practice. The WBLM must work in conjunction with other measures to address human and system factors in prescribing errors. These effects should be studied with ongoing PDSA cycles.

PS-012 Medicines reconciliation in the intensive care unit

Background Medicines reconciliation is known to minimise medicines errors and reduce morbidity in hospitalised patients. Its role in the Intensive Care Unit (ICU) has not been widely studied. Purpose To analyse the number, type, and importance of pharmacist contributions in the ICU of a tertiary level hospital. Material and methods Prospective study conducted in July 2014 to assess the accuracy of in-patient prescription charts. Drug history and medicines reconciliation were undertaken within the first 24 h by a specialist pharmacist. The patient’s own medicines, information from relatives or carers and community pharmacy records, were used as sources of information. Discrepancies between the patient’s regular medicines and prescribed medicines were conveyed to the medical team. Discrepancies were considered medicines errors when they required further intervention by the responsible doctor. Results 48 patients were included, percentage of females 39.6%, mean age 62 ± 14.04. Average number of regular medicines per patient: 5.41 ± 3.5. Discrepancies were found in 62.5% of patients, of which 79.9% required pharmacy intervention (the rest of them were obviated due to the patient’s clinical condition – mostly inability to swallow). These involved 98 out of 260 drugs prescribed. Of them, the contribution was accepted in 51.3% of cases (40 prescriptions), whereas in the remainder 48.7% of cases, the changes were intentional. According to their pharmacological class, the highest number of contributions was found in anti-hypertensives (9 contributions), followed by statins (6) and diuretics (6). In relation with the type of medicine involved, a total of 33 medicines errors were accountable as omissions, whilst wrong directions were found in 4 cases, and wrong dose occurred in 3 cases. Conclusion Medicines errors in the ICU have a similar incidence to those in other non-acute clinical settings. This study is in line with previous publications, suggesting that the ICU might benefit from the regular input from a pharmacist, which in turn would result in a reduction of medicines errors. References and/or acknowledgements No conflict of interest.

AUDIT AND RE-AUDITS OF MEDICINE ADMINISTRATION RECORDS ON PAEDIATRIC INPATIENT PRESCRIPTION CHARTS—MISSED DOSE OR MEMORY LOSS

AimTo demonstrate that administration of medicines, or omissions, are recorded clearly and accurately on paediatric inpatient prescription charts, in accordance with the Trust medicines management policy. To provide evidence to...

Developing a standardised prescription chart to reduce error

Unfamiliarity is an important contributor to error, including medication errors, some of which result in adverse events. Paper-based inpatient prescription charts differ in different hospitals, and medical trainees move around health care systems, so they may be unfamiliar with such charts initially.

GRP-084 How Has the Introduction of New Drug Charts Affected Prescribing Documentation?

BackgroundUniversity Hospitals Bristol (UHBristol) have standards for safe and professional prescribing [1]. The standards include prescriber accountability and informed clinical decision making by awareness of drug chart(s) in use and...

Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions

AimTo improve medication history accuracy and reduce prescribing errors for unscheduled patients admitted via the emergency department (ED).DesignA prospective observational study of 100 adult unscheduled admissions with 50 patients in...

Medication histories: does anyone know what medicines a patient should be taking?

Abstract Objective To determine and evaluate the accuracy of physician-acquired medication histories for patients admitted to the surgical and medical admission units in a large teaching hospital in the UK. Method The pharmacist obtained a medication history, including allergy status, by interviewing the patient. This was compared with the physician's history as documented in the medical notes and with a third source, for example general practitioner (GP) records, and then with what was prescribed on the inpatient prescription chart. Key findings In total, 126 medical patients and 51 surgical patients were reviewed. 102 (17%) medicines were prescribed on the inpatient chart but not documented in the medical notes; 179 (16.7%) medicines were documented in the notes but not prescribed on the prescription chart, with no explanation by the doctor; 75 (9.8%) medicines were documented in the notes by doctor with no dose; 227 (41%) medicines from pharmacist interview were not prescribed on the chart; 189 (34.1%) medicines were identified from pharmacist interview but not recorded in the notes; 113 (28.9%) medicines from pharmacist interview had a dose that was different in the notes; 45 (12.8%) medicines from pharmacist interview had a dose that was different on the chart; and 103 (21.1%) medicines from pharmacist interview had a dose different from that in the third source. A total of 51 medicines were identified from the pharmacist interviews that were not on the records of the GP or nursing home, and these accounted for approximately 5% of all medicines recorded. Conclusion This study supports the findings of previous studies that there are substantial numbers of discrepancies between documented sources of patients' medicines and what patients report they are taking. Furthermore our findings add to existing knowledge by highlighting the need for clearer and more complete documentation of medication histories in the patient's medical notes. The inaccuracies observed with GPs' records and in comparison with hospital records suggest that currently there is no ‘gold standard’ medication history available, other than a list of drugs taken from a patient who is perceived to be ‘reliable’.

Safe prescribing by junior doctors

Tobaiqy et al. in a recent study have reported that Foundation Year 1 (FY 1) doctors lack confidence in prescribing several groups of drugs [1]. The majority of the FY 1 doctors felt that undergraduate education in clinical pharmacology and therapeutics (CPT) had not prepared them adequately for prescribing duties. CPT of drugs that are commonly prescribed across specialties, e.g. analgesics, anti-inflammatories, antacids, antibiotics, antihypertensives and anticoagulant drugs, should be adequately taught to medical students because they are likely to be encountered on a doctor's first day on the ward after graduation. However, it is not possible to teach the whole formulary in depth to medical students, and drugs that are more specific to certain specialties are probably best taught during specialty postings. Moreover, there are considerable differences in local formularies between NHS hospital trusts in the UK. This poses a challenge in terms of what drugs should be taught and in how much detail, as students may move to a new region for FY training following graduation. Confidence in prescribing comes from practice and familiarity with a particular drug on the ward. CPT is taught in most medical school curricula, but students have difficulty translating the theory into practice until they are faced with the responsibility of making prescribing decisions [2, 3]. Even though medical students may be taught to write prescriptions which are countersigned by a doctor, confidence only comes with practice, responsibility and adequate supervision. Aronson [4] has rightly noted that the writing of the prescription is a late event in the prescribing process and describes four preceding steps: (i) making an accurate diagnosis, (ii) assessing the balance of benefit to harm, (iii) choosing the right drug among a range of alternatives and the right dose regimen, and (iv) discussion with the patient about the proposed treatment and potential beneficial and adverse effects. It would be difficult to teach medical students all of these steps for all the drugs in the formulary and it is not time efficient to attempt to do so. More focus should be placed on teaching the principles of writing a proper prescription, which applies to any drug being prescribed. This is relevant to medical students as well as practising doctors, and should be a core part of continuous professional development programmes. Many doctors who are able to prescribe drugs confidently are unfortunately unable actually to write clear legible prescriptions that can be dispensed or administered without confusion [5, 6]. These findings are in keeping with unpublished audits done by the authors in two District General Hospitals in the north and south of England. A snap-shot of prescribing practices in the orthopaedic directorate of both hospitals was done at the beginning of the audit cycle. The percentage of inpatient prescription charts with errors in both hospitals was 54% and 60%, respectively. Most of the drugs were analgesics, anti-inflammatory drugs and antibiotics. There were no FY 1 doctors working in either of the units, so all the prescriptions had been done by doctors who had been prescribing for >1 year. The doctors frequently did not know the local prescribing guidelines or how to obtain them. We think that these audits suggest that prescription writing is poor even among doctors who are confident about the CPT of the prescribed drugs, and that knowing what drug to prescribe to which patient does not necessarily translate to a good prescription. Various reasons have been identified for doctors writing wrong prescriptions [7], but it is an issue that needs to be addressed continuously throughout a doctor's professional career. We do not believe all drug-prescribing issues can be adequately and sufficiently addressed during undergraduate medical training.

Prescribing of clozapine and olanzapine: dosage, polypharmacy and patient ethnicity

Aims and MethodThe aim of this study was to determine the existence and extent of differences in prescribing practice for patients according to ethnic group, with two widely used atypical antipsychotics, olanzapine and clozapine. All in-patient prescription charts were screened and patients receiving olanzapine and clozapine identified. Dosage, antipsychotic co-prescription and race were recorded, along with demographic details, and evaluated using comparative statistical analysis.ResultsOverall, 1441 prescriptions were screened; 328 patients received olanzapine and 200 clozapine. Details of ethnic origin were available for 287 of those prescribed olanzapine and 188 of those prescribed clozapine. There was no significant difference between ethnic groups in age or gender, for either drug. For clozapine, dosage and extent of antipsychotic co-prescription did not differ significantly between ethnic groups; for olanzapine, there was no significant difference in daily dose between the groups, but co-prescription was significantly more common in Black (33%) than in White patients (20%; P=0.023).Clinical ImplicationsImportant differences in the prescription of olanzapine and clozapine between ethnic groups are uncommon, but demand further investigation. Larger studies incorporating additional baseline details such as diagnosis and body weight are called for.

A Study to Determine the Importance of Ward Pharmacists Reviewing Discharge Prescription

Objective: To evaluate the potential impact on appropriateness of discharge medication if discharge prescriptions were reviewed by the ward pharmacist before being dispensed.Method: Over a four‐week period discharge prescriptions were reviewed by either the ward pharmacist involved in the patient's care (cases) or a dispensary pharmacist who had no knowledge of the patient's care (controls). A second review with the availability of patient records was carried out to identify additional queries that should have been raised prior to dispensing.Results: Fifty‐five prescriptions (29 case, 26 control) containing 279 items (140 case, 139 control) were reviewed. Forty‐four queries (23 case, 21 control) were found on initial checking of the prescription, 12 more queries (1 case, 11 control) were found on the second review of the prescription. There were 13 potentially clinically significant queries in the case group, 12 (92%) were made during initial prescription review. There were 23 potentially clinically significant queries in the control group, only 12 (52%) were made on initial prescription review. Changes to the prescription resulting from potentially clinically significant queries prior to dispensing occurred in 19 (79%) queries (10 case, 83%; and 9 control, 75% ). Of queries raised prior to dispensing in the control group, 18 involved contacting hospital staff for resolution where they could have been resolved using the inpatient prescription chart, notes or the patient themselves. This compared to only one in the case group.Conclusion: Review of discharge prescriptions by the ward pharmacist involved in the patient's care optimises the appropriateness of discharge medication and the efficiency of the discharge process.