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Multidisciplinary Teaching for Prescribing Safety
- 1. Multidisciplinary Teaching and Learning in Prescribing and Medicines Safety
- 2. Background Prevalence, Incidence and Nature of Prescribing Errors in Hospital Inpatients: A Systematic Review . Drug Safety 2009; 32(5):379-389 7% 93%
- 3. Final year OSCE station 2009- Prescribing
- 5. Team approach to preventing drug related errors
- 8. Interaction
- 12. Data from lecture series: 1. Practical prescribing 2. Voting results
- 16. Different medication choices Confidence in vote cast
- 17. Course of action when initial medication questioned Confidence in choice
Editor's Notes
- NAME TALK ABOUT …
- A recent systematic review was carried out by senior members of the schools of Pharmacy and Medicine here at the University and was published at the beginning of 2009. They looked at and summarised studies which investigated the prevalence, incidence and nature of prescribing errors in hospital inpatients. Overall, studies show that prescribing errors are a common occurrence, affecting around 1 in 14 of all hospital prescriptions. Foot note Why did we look at this? Know prescribing error is a big problem Example- recent systematic review carried out by senior members of the schools of Pharmacy and Medicine (including Val Wass) at the University- 1 in 14 hospital prescriptions contain errors.
- Around 80% of final year medical students failed an OSCE station examining practical prescribing in the January exemption exams. Also, around 80% of our fifth year medical students failed a prescribing OSCE station at their exemption examinations this year. Obviously prescribing is an area which needs addressing in the medical school.
- Medication error is in the news a lot… BBC Report on 7 th October regarding latest NPSA figures. 2 nd area for mistakes – treatment and medication (after accidents) 6% - resulted in moderate harm and 5,717 - 1% - in death or severe harm, which is classed as permanent injury or disability. We need to build an even stronger safety culture of reporting and learning to prevent harm to future patients To further back this up- Medication error is in the news- it is a national problem Lots of public interest and concern Finally- why have I been particularly interested in this aspect of teaching and learning? I was a hospital pharmacist prior to medical training, and now as a GP have a regular prescribing commitment. I met with a team of like minded tutors at the schools of pharmacy and medicine and discussed this area of teaching and learning .
- We wanted the students to appreciate the importance of a team approach to preventing drug error. We also wanted to facilitate some kind of communication between the pharmacists and medics. We wanted the students from different specialities to be able to appreciate each other’s perspectives when confronted with drug safety issues. We also wanted the students to realise that different members of the healthcare team all have useful roles in providing safe patient care. Some things we are happy with, some things we need more advice on. We wanted to explore whether confidences in decision making varies depending on the question confronted by an individual professional. We talked about addressing this; medication is prescribed by doctors and more recently by pharmacists and nurses. But drug errors do not occur only during prescribing. They also occur during dispensing and administration of medication. We therefore thought it was best to introduce some multi-professional teaching to emphasise the importance of a team approach to preventing drug error.
- We wanted to look at this in the medical school, and this was mirrored in the schools of Pharmacy. Several members of the schools met, and it was decided that we needed to deliver something, and something more than a single passive lecture. In an ideal world, small group learning seemed to fit best with this, but the practicalities were onerous- tutoring? Rooms? Materials? Interprofessional commnication? Etc. We thought the ideal would be to go beyond passive learning- face to face tutor lead mixed small group teaching sounded perfect, but it soon became apparent that logistically this was not feasable.
- Today I will talk about a component of our work that is now completed- An interactive Mini lecture series delivered to Medics and Pharmacists in parallel This component was delivered to both disciplines to help them understand how medication errors arise, and to develop a systematic approach towards drug error prevention and reporting. The interactive elements of the lecture series allowed some communication between the lecture tutors and the attending students, and between students in the medical and pharmacy school. To tackle logistical problems, we decided to deliver 3 lectures to final year medical and pharmacy students and follow this up with some small group work in a virtual learning environment. It wasn’t possible to get medics and pharmacists in the same lecture theatre at the same time, so we ran the lecture series in parallel to the two groups.
- After some background regarding medication error and patient safety, students were presented with case scenarios to consider in the lecture. Students were presented with dilemmas and asked to vote for an option presented to them Sometimes these dilemmas concerned an individual’s choice when facing the dilemma. Sometimes these dilemmas looked at system changes that might reduce error by all staff in the future. We gave the students some background information regarding patient safety and medication error They were then presented with some clinical problems and had to vote on a course of action from a list of possible options.
- As well as voting for their course of action….
- .. We asked students how confident they felt with the vote they had cast. We wanted to measure this, as it might highlight situations where confidence in their vote was inappropriately high or low.
- We wanted to give the students some practical guidance for safer prescribing. At some points in the lectures, students were asked to undertake some prescribing, particularly after voting for a certain medication when presented with several choices. Alongside the voting papers, students were presented with a blank hospital prescription chart, and were also given some short excerpts from the BNF regarding the choices of medication they had been presented with. We also gave the students a hospital drug chart to give them some practical prescribing opportunities. We gave them appropriate excerpts from the BNF to help with this
- Background completed. Now I am going to show you some practical prescribing examples and some interesting results from the voting.
- We presented anonymised example charts at subsequent lectures. Sometime this is because the student had demonstrated a safe and effective prescribing skill We used the prescription charts for feedback to the students in subsequent lectures We anonymised example charts and scanned them in for presentation at subsequent lectures This is an example of a chart we used to highlight good practice- neat, legible, a review date added for the antibiotics
- Sometimes there were some errors which we thought would cause confusion. We also used charts to highlight prescribing which may cause confusion We bought these to students attention.
- Sometimes it seemed that students had made simple slips when put under pressure, we were able to use this as a learning tool for real life- we told the students that they should take care when prescribing, make sure that they tried to do so in a quiet area without undue rush. Very reassuring to see prescribing quality was much improved by the end of the mini lecture series.
- In terms of voting, medical and pharmacy students mirrored each other in some situations… For example, one of the clinical dilemmas asked the students to think about initial medication choices for a patient in pain after an operation. The spread of choices made were similar in both groups, their confidence in the choice they had made was also similar, with most students feeling quite confident with the vote they cast. Interesting voting results Some instances where medics and pharmacists results were very similar This was both in terms of their chosen course of action and confidence levels
- Sometimes both groups voting patterns were similar when confronted by further dilemmas, but confidence in the vote they had cast was lower in the pharmacy group. It seemed medical students were happier to ask for help when things got complicated. On other occasions, differences were highlighted. In this example, although the majority of both pharmacy and medical students felt asking for help was most appropriate, medics were much more confident. We think this may reflect medics being more used to dealing with uncertainty through their clinical experience and problem based learning .
- Sometimes choices were quite split, particularly when faced with possible system changes. For example, we asked students about a case scenario regarding clostridium difficile infection. Pharmacy students were keen to restrict prescribing to prevent clostridium difficile infection in hospitals, with around a third going for this. As the main group of prescribers, it is not surprising that medics were slightly keener on prescriber education as an effective method to reduce clostridium infection. Medics seemed keener on minimising admissions in the first place!
- We have since gone on to pilot some small group teaching and learning in medication safety for medical and pharmacy students. They have been working together using a virtual environment to consider some mock case histories where medication safety issues abound.
- Pharmacists and medics have been discussing the case material using virtual discussion boards, and are working on group reports to address the issues in medication they identify.
- Background- Work in Norway looking at nurse drug calculation multiple choice questions and certainty scoring- 88% did not complete all calculations in the test, 7% were certain that their answers were correct when in fact they were wrong. Work in Cambridge 2004- calculation of drug doses in solution- 10% students were able to answer all questions correctly, 27% got every question wrong. Voting – forced choice- no middle ground, similar with confidence rating. Recent research (Koh et al, National University of Singapore) shows PBL supports: Coping with uncertainty Appreciation of legal, ethical and cultural aspects of health care Communication skills- these are improved by PBL process How many errors on scripts- around 25% demonstrated clear errors after the first lecture, however we decided to avoid quantitative analysis; we used the scripts for feedback to demonstrate examples of good practice and examples that might cause confusion. It is difficult to analyse prescribing like this anyway- as the drug safety systematic review outlined, defining what we mean by “prescription error” is already fraught with danger and misconception. VLE – main barrier to further involvement of medical students is that this is not directly summatively assessed (but is on pharmacy course). I do feel that we should look at introducing high stakes assessment in practical prescribing and medication safety to ensure this is considered and taken more seriously by all medical students.