Medication errors pose a major threat to patient safety. In England and Wales, over 50 000 medication incidents in National Health Service hospitals are reported annually to the UK National Patient Safety Agency . Multiple factors are involved in these events, including faulty supply and labeling and errors of administration, but poor prescribing is probably the most common cause of avoidable events, accounting for over half of all preventable hospital medication errors .
Most serious hospital medication errors concern dose, and around 90% involve junior doctors who have recently graduated from medical school , making them an important potential target of intervention to improve patient safety.
It should come as no surprise that prescribing is associated with error. Prescribing is a complex and challenging task that requires diagnostic skills, knowledge of medicines, communication skills, an understanding of the principles of clinical pharmacology, appreciation of risk and uncertainty, and, ideally, experience. It is an anomaly that the hospital doctors who have least experience are expected to prescribe most often.
It is also apparent that the demands on new prescribers are increasing progressively, owing to several important trends, including (i) the availability of an increasing number of licensed medicines with complex actions; (ii) an increasing number of indications for drug treatment; (iii) greater complexity of treatment regimens, leading to inappropriate polypharmacy; and (iv) more elderly and vulnerable patients.
Recent changes in Undergraduate Education
Undergraduate medical education has undergone considerable transformation in the last two decades. These changes have come in response to concerns that students were overburdened with scientific facts and were being taught in rigid traditional discipline-based courses, with little regard to social sciences, notably communication skills. The General Medical Council (GMC), which regulates education in the UK, responded to these concerns by publishing a template for medical education, Tomorrow’s Doctors, in 1993 .
This heralded a major change in direction, promoting a reduction in ‘factual burden’, integration of the curriculum ‘both vertically and horizontally’, and learning based on body systems. It ‘avoided all reference to traditional subjects and disciplines . . . urging the advantages of interdisciplinarity’. These changes had an adverse effect on the teaching of clinical pharmacology and therapeutics (CPT), a traditional discipline that is factually rich and not organ-based.
Identifiable courses and assessments in pharmacology and CPT disappeared in many schools, along with the teachers and departments who had delivered them . As a result, many UK medical students now have little exposure to clinical pharmacologists or indeed any CPT or teaching about practical prescribing.
This lack of specialists in a discipline dedicated to fostering safe and rational use of medicines has even led some schools to call on pharmaceutical company support for teaching . The current standards set out for training nurse prescribers in the UK, ‘a minimum of 26 days, with an additional 12 days of supervised learning practice’ ,would be the envy of many medical students .
Are medical students trained for safe prescribing?
It has been difficult to resolve these opposing views, for several reasons. First, there has been little agreement about the required outcome of undergraduate education and no clear statement of the knowledge and skills that might be expected of a new doctor about to become a prescriber.
Second, achieving consensus on the required outcome is complicated by uncertainties about what is actually required of junior prescribers in their workplace and what level of supervision they receive.
Third, very few medical schools now run exit assessments that focus specifically on safe prescribing and might provide clear evidence of educational attainment.
Are education or training factors in prescribing errors?
It has been difficult to resolve these opposing views, for several reasons. First, there has been little agreement about the required outcome of undergraduate education and no clear statement of the knowledge and skills that might be expected of a new doctor about to become a prescriber. Second, achieving consensus on the required outcome is complicated by uncertainties about what is actually required of junior prescribers in their workplace and what level of supervision they receive. Third, very few medical schools now run exit assessments that focus specifically on safe prescribing and might provide clear evidence of educational attainment.
Do educational interventions reduce medication errors?
There are obvious difficulties in delivering such evidence because of the large numbers of students required, the long and detailed follow-up, difficulty detecting medication-related events and measuring the quality of prescribing practice, achieving random allocation of learning experience, constant change in curricula, and overcoming the confounding effects of other relevant factors such as working environment and postgraduate education.
However, several studies have shown that educational interventions can improve prescribing performance, although most have relied on assessments early after intervention and under controlled conditions rather than on hospital wards.
Other uncertainties exist. When is the ideal time to provide education? We are among many commentators who believe that the undergraduate stage is a critical period, because courses are of prolonged duration (5–6 years full time), are undertaken when long-term attitudes and skills can best be developed, and are the only preparation available before the assumption of legal responsibility for prescribing.
In contrast, postgraduate interventions are significantly limited by time constraints imposed by clinical schedules, are more difficult to supervise effectively, and compete with other training requirements (e.g. resuscitation skills). However, postgraduate education does have the potential advantage that it would be delivered when prescribing skills are frequently practiced in a clinical setting.
The rise of problem-based learning has been a major educational trend, and prescribing education lends itself extremely well to this format, although in one recent study there was no benefit over more traditional didactic methods . An alternative and increasingly popular approach is the development of eLearning packages to support rational prescribing [29–31], allowing learning opportunities to be taken up flexibly at times that best suit learners, a major potential advantage for postgraduates. However, evidence of efficacy is still awaited.
Recommendations for improved training in prescribing
Irrefutable evidence that more prescribing training will reduce the harm patients suffer from medication errors has yet to emerge. However, the combination of widely voiced concerns about existing education, growing challenges faced by prescribers, and the relative ease with which errors are identified has led many to advocate precautionary change [32–35]. Important steps have been taken in the UK, where the GMC and the Medical Schools Council convened a Safe Prescribing Working Group, which brought together representatives of relevant stakeholders.
For the first time it was possible to achieve consensus on a list of prescribing competencies that should be expected of all graduates of medical schools and against which undergraduate education can be judged  (Table 1). Although this is an advance, it has not addressed the central question of how these outcomes can be achieved.
Medical education has changed greatly in recent years, often for the good. However, it is a matter of regret that specific courses in clinical pharmacology and therapeutics, the discipline that underpins safe and effective prescribing, have been lost. Teaching and training of prescribers form only part of the approach to protecting patients from medication errors.
Support from other colleagues (for example, clinical pharmacists) will be vital, along with the spread of electronic prescribing with decision support, but we believe that it will ultimately be the knowledge and instincts of prescribers that will be their most important protection against irrational and unsafe use of medicines.
--Likic, R., & Maxwell, S. J. (2009). Prevention of medication errors: teaching and training. British Journal Of Clinical Pharmacology, 67(6), 656-661. doi:10.1111/j.1365-2125.2009.03423.x
Reflection Exercise Explanation
Goal of this Home Study Course is to create a learning experience that enhances
your clinical skills. We encourage you to discuss the Personal Reflection
Journaling Activities, found at the end of each Section, with your colleagues.
Thus, you are provided with an opportunity for a Group Discussion experience.
Case Study examples might include: family background, socio-economic status, education,
occupation, social/emotional issues, legal/financial issues, death/dying/health,
home management, parenting, etc. as you deem appropriate. A Case Study is to be
approximately 100 words in length. However, since the content of these Personal
Reflection Journaling Exercises is intended for your future reference, they
may contain confidential information and are to be applied as a work in
progress. You will not
be required to provide us with these Journaling Activities.
Reflection Exercise #1
The preceding section contained information
about teaching and training. Write one case study example
regarding how you might use the content of this section in your practice.
What do most serious hospital medication errors concern? Record the letter of the correct answer the
for this course |
Excerpt from Bibliography referenced in this article
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2. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R, Vandser Vliet M, Nemeskal R, Leape LL. Incidence of adverse drug events and potential adverse drug events: implications for prevention. ADE Prevention Study Group. JAMA 1995; 274: 29–34.
3. Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care 2002; 11: 340–4.
7. General Medical Council. Tomorrow’s Doctors. London: General Medical Council, 1993.
8. Maxwell SRM,Webb DJ. Clinical pharmacology – too young to die? Lancet 2006; 367: 799–800.
9. Coombes R. The pharmaceutical industry is stepping in to fill the therapeutics void. BMJ 2009; 338: 70–1.
10. Nursing & Midwifery Council. Standards of Proficiency for Nurse and Midwife Prescribers. London: Nursing & Midwifery Council, 2006.
11. Ellis A. Prescribing rights: are medical students prepared for them? BMJ 2002; 324: 1591.
28. Likic R, Vitezic D,Maxwell S, Polasek O, Francetic I. The effects of problem-based learning integration in a course on rational drug use: a comparative study between two Croatian medical schools. Eur J Clin Pharmacol 2009; 65: 231–6.
29. Maxwell SRJ,McQueen DS, Ellaway R. eDrug: a dynamic interactive electronic drug formulary for medical students. Br J Clin Pharmacol 2006; 62: 673–81.
30. Smith A, Tasioulas T, Cockayne N,Misan G,Walker G, Quick G. Construction and evaluation of a web-based interactive prescribing curriculum for senior medical students. Br J Clin Pharmacol 2006; 62: 653–9.
31. Franson KL, Dubois EA, de Kam ML, Cohen AF.Measuring learning from the TRC pharmacology e-learning program. Br J Clin Pharmacol 2008; 66: 135–41.
32. British Medical Association Science and Education Department. Evidence-based Prescribing. London: BMA, 2007. Available at http://www.bma.org.uk/health_promotion_ethics/drugs_prescribing/evidencebasedprescribing.jsp
33. Audit Scotland. A Scottish Prescription:Managing the Use of Medicines in Hospitals. Edinburgh: The Scottish Executive, 2005. Available at http://www.audit-scotland.gov.uk/ utilities/search_report.php?id=253
34. Royal College of Physicians. Innovating for Health: Patients, Physicians, the Pharmaceutical Industry, and the NHS. Report of a Working Party. London: Royal College of Physicians, 2009.
35. Horton R. The UK’s NHS and Pharma: from schism to symbiosis. Lancet 2009; 373: 435–6.
36. Lechler R, Paice E, Hays R, Petty-Saphon K, Aronson J, Bramble M, Hughes I, Rigby E, Anwar Q,Webb D,Maxwell S, Martin J,Maskrey N,Walker S. Outcomes of the Medical Schools Council Safe Prescribing Working Group, November 2007. Available at http://www.chms.ac.uk/documents/ finalreport.doc (last accessed 14 February 2009).