1. Exploring the effectiveness of prescribing error feedback in an acute hospital setting
Authors: Michael Lloyd, Dr. Simon Watmough, Prof. Sarah O’Brien, Prof. Kevin Hardy, Dr. Niall Furlong. Contact
Abstract
Design & Methodology
Results
Background: Prescribing errors (PEs) are prevalent within healthcare with lack of prescriber feedback considered a contributing factor.
Aims: This study aims to determine the impact of pharmacist-led, constructive feedback, on prescribing error rates.
Methods: This was a controlled before and after study. Prescribers in the intervention group (n=37) received constructive feedback from pharmacists. The control group (n=41) continued with existing practice. Prescribing was audited at baseline and following three months of the intervention.
Results: PE rates improved by 23.8% (p<0.05) between groups with significant (p<0.05) reductions in all error types and severity in the intervention group.
Conclusion: Pharmacist-led PE feedback is an effective intervention that can reduce PEs and improve patient safety.
The intervention:
Based on principles of effective feedback.2
Pharmacists trained in delivery of feedback.4
Feedback delivered verbally and in writing:
Every four months for all prescribing and;
For every significant PE.
Delivered by ward-based pharmacist.
Prescriber includes a copy in their training portfolio.
Pharmacy keep a copy in secure folder.
Methods*:
Prescribing was audited on sixteen wards (eight intervention, eight control) over five days at baseline and three months following the intervention to determine the impact on PE rates.
Change in PE rates were compared using independent t-tests with chi squared tests and spearman rank tests used for univariate analyses and tests of association.
*Ethical approval obtained for all studies.
Figure 3: Bar chart illustrating distribution and number of PE types for the intervention group
Discussion
Background
Results
Pharmacist-led feedback reduces PEs. Feedback can raise awareness of prescriber performance (see figure 4), challenging their perceptions and informing learning needs. This in turn allows change in prescribing behaviour to reduce the gap between perceived and actual prescribing performance.
Figure 4: Conscious competence prescribing model
Prescribers have reported increased information and feedback seeking behaviour following PE feedback and greater team work with their pharmacists. 2 Such a co-operative approach to prescribing can only benefit patient safety and care.
It is possible that doctors amend their prescribing to avoid unfavorable feedback or comparison to their peers especially if they are performance oriented individuals.
However, irrespective of motivation, this study supports the need for feedback to raise prescriber awareness of error, encourage self-reflection and allow them to adapt their prescribing.
PEs are prevalent in the hospital setting with reports suggesting error rates of 1.5% to 52%.1,2
Where PEs occur, resources are wasted and patient care compromised. Interventions to address the problem have focused on educational and system interventions, yet PEs remain a concern.
Figure 1: Kolb’s experiential learning cycle.4
Prescribers have reported a lack of awareness and feedback on PEs previously.2,3 Without feedback, prescribers may have false perceptions of their prescribing.4 Feedback is reported to improve task performance, including prescribing, and underpins the experiential learning cycle to catalyze professional development (see figure 1).4
Feedback is considered most effective when it is constructive, raising self-awareness, identifying learning needs and motivating individuals to address those needs with clear action plans. 4 As pharmacists are a key defence in intercepting PEs, they are considered best placed to deliver PE feedback. 1
Over 5000 items were audited at baseline and post-intervention.
There were 37 prescribers in the intervention groups and 41 in the control group.
Prescriber grade ranged from Foundation year 1 to consultant. Results are presented in table 1.
Table 1: Pre- and post-intervention error rates in the intervention and control groups
Significant improvements were consistently reported for both inpatient and discharge prescribing.
Significant reductions were reported for PE rates of all prescriber grades (Figure 2), error severities and types (Figure 3), within the intervention group.
Figure 2: Bar chart illustrating PE rates by prescriber grade for the intervention group
There was no association (p=0.46) between intensity of feedback and reduction in PE rates.
588 less PEs were recorded over five days in the intervention group.
Potentially saving >130,000 PEs and >32,000 hours per year across the Trust.
Prescriber unaware of a partiuclar deficit in prescribing performance
Unconscious Incompetence
Prescriber understands the importance of a particular aspect of prescribing, but completes prescription incorrectly
Conscious Incompetence
Prescriber completes each step of the prescribing process but has to think about each step
Conscious Competence
Prescriber prescribes correctly without much thought
Unconscious Competence
Pre-intervention
Post-intervention
Mean change
Overall change
Intervention
Control
Error free Prescription %
48.4%
53.7%
72.1%
47.9%
+23.7%
-5.8%
+29.5% (p<0.05)
Prescribing error rate %
25%
19.7%
6.7%
25.2%
-18.3%
+5.5
-23.8% (p<0.05)
Constructive prescribing performance feedback
Conclusion
Pharmacist-led feedback positively influences prescribing and is now part of routine practice in our Trust. This intervention can reduce harm from PEs, and facilitate medicines optimisation by supporting development of prescribing competence and improving patient safety.
Aims
Determine the impact of pharmacist-led feedback on prescribing error rates in a hospital setting.
To address this aim a quasi-experimental design was used incorporating a before and after design to compare the impact of PE feedback between control and intervention groups.
References
1. Lloyd M, Watmough SD, O'Brien SV, Furlong N, Hardy K. Res Social Adm Pharm. 2016;12(3):461-74
2. Lloyd M, Watmough SD, O'Brien SV, Furlong N, Hardy K. Br J Hosp Med (Lond). 2015; 2:76(12):713-8
3. Velo GP, Minuz P. Br J Clin Pharmacol 2009;67:624–628.
4. Lloyd M, Watmough SD, O’Brien SV, Furlong N, Hardy K. The Pharmaceutical Journal, 2016; Vol 296, No 7887, online