How to Prevent or Reduce Prescribing Errors: An Evidence Brief for Policy.
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ABSTRACT:
SUBMITTER: de Araujo BC
PROVIDER: S-EPMC6584796 | biostudies-literature | 2019
REPOSITORIES: biostudies-literature
Publications
How to Prevent or Reduce Prescribing Errors: An Evidence Brief for Policy.
de Araújo Bruna Carolina BC de Melo Roberta Crevelário RC de Bortoli Maritsa Carla MC Bonfim José Ruben de Alcântara JRA Toma Tereza Setsuko TS
Frontiers in pharmacology 20190612
- Preventing prescribing errors is critical to improving patient safety.- We developed an evidence brief for policy to identify effective interventions to avoid or reduce prescribing errors.- Four options were raised: promoting educational actions on prudent prescribing directed to prescribers; incorporating computerized alert systems into clinical practice; implementing the use of tools for guiding medication prescribing; and, encouraging patient care by a multidisciplinary team, with the parti ...[more]
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Project description:ImportanceBenzodiazepines have been a common target for policy interventions to curtail inappropriate use, with mixed results. To reduce alprazolam misuse, in February 2017, Australia delisted the 2-mg tablet strength from public subsidy, eliminated refills, and reduced the pack size from 50 tablets to 10 tablets.ObjectiveTo describe changes in alprazolam dispensing, prescribing, and poisonings associated with the implementation of a new policy to reduce inappropriate prescription of alprazolam in Australia.Design, setting, and participantsThis interrupted time series analysis and cross-sectional study included data from a 10% sample of Australian people who received publicly subsidized dispensing claims and prescribing approvals for alprazolam from January 1, 2015, to December 31, 2018, and all calls to a poison information service involving alprazolam from February 1, 2015, to October 31, 2018. Autoregressive error models were used to quantify changes over time and compare patterns of use before and after the intervention. Data analyses were conducted from November 2018 to May 2019.ExposureImplementation of the policy change on February 1, 2017.Main outcomes and measuresMonthly trends in alprazolam prescribing approvals and dispensings, quarterly trends in telephone calls involving alprazolam to a poison information service, and patterns of prescribing and dispensing before and after the intervention.ResultsFrom 2015 to 2018, there were 71?481 alprazolam dispensings to 6772 people. After the intervention, overall dispensing decreased by 51.2% (95% CI, 50.5%-51.9%) and prescribing approvals increased by 17.5% (95% CI, 13.0%-22.2%). Overall, the proportion of dispensing of packs of 51 to 100 tablets increased from 5776 of 24?282 dispensings (23.8%) to 4888 of 10?676 dispensings (45.8%) (risk difference [RD], 22.0% [95% CI, 19.4%-24.6%]) and dispensing of packs of more than 100 tablets increased from 1029 of 24?282 dispensings (4.2%) to 1774 of 10?676 dispensings (16.6%) (RD, 12.4% [95% CI, 10.6%-14.2%]). Among people receiving their first alprazolam prescription, initiation with packs of 10 tablets or fewer increased from 16 of 1127 people (1.4%) before the intervention to 139 of 589 people (23.6%) after the intervention (RD, 22.2% [95% CI, 18.7%-25.7%]). Alprazolam treatment initiation with packs of more than 50 tablets also increased from 63 of 1127 people (5.6%) before the intervention to 144 of 589 people (24.4%) after the intervention (RD, 18.9% [95% CI, 15.1%-22.6%]). During 1 year before the intervention, patients received a median (interquartile range [IQR]) total of 250 (50-600) tablets and median (IQR) total combined tablet strength of 188 (50-550) mg. During 1 year after the intervention, people were dispensed less alprazolam, with a median (IQR) total of 200 (50-500) tablets and median (IQR) total combined tablet strength of 120 (30-360) mg. There was little change in poisoning calls involving alprazolam.Conclusions and relevanceThis study found that after the policy intervention, subsidized alprazolam use decreased, but the increase in prescribing approvals placed additional burden on prescribers. Even after the intervention, most people who were dispensed alprazolam were still receiving treatment contrary to best-practice recommendations. Furthermore, the poison information center data suggested that people were still being dispensed the 2-mg tablet strength, presumably as nonsubsidized (ie, private) prescriptions.
| S-EPMC6751760 | biostudies-literature
Project description:AimsTo develop and evaluate a feasible, authentic pharmacist-led prescribing feedback intervention for doctors-in-training, to reduce prescribing errors.MethodsThis was a mixed methods study. Sixteen postgraduate doctors-in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi-structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically.ResultsDuring the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P < .0001). Pharmacist-led video-stimulated prescribing feedback was feasible and positively received by participants, who appreciated the reinforcement of good practice as well as the opportunity to reflect on and improve practice.ConclusionsFeedback to doctors-in-training tends to be infrequent and often negative, but this feasible feedback strategy significantly reduced prescribing errors and was well received by the target audience as a supportive developmental approach.
| S-EPMC6783579 | biostudies-literature
Project description:ObjectiveTo report the frequency, types, and causes of errors associated with outpatient computer-generated prescriptions, and to develop a framework to classify these errors to determine which strategies have greatest potential for preventing them.Materials and methodsThis is a retrospective cohort study of 3850 computer-generated prescriptions received by a commercial outpatient pharmacy chain across three states over 4 weeks in 2008. A clinician panel reviewed the prescriptions using a previously described method to identify and classify medication errors. Primary outcomes were the incidence of medication errors; potential adverse drug events, defined as errors with potential for harm; and rate of prescribing errors by error type and by prescribing system.ResultsOf 3850 prescriptions, 452 (11.7%) contained 466 total errors, of which 163 (35.0%) were considered potential adverse drug events. Error rates varied by computerized prescribing system, from 5.1% to 37.5%. The most common error was omitted information (60.7% of all errors).DiscussionAbout one in 10 computer-generated prescriptions included at least one error, of which a third had potential for harm. This is consistent with the literature on manual handwritten prescription error rates. The number, type, and severity of errors varied by computerized prescribing system, suggesting that some systems may be better at preventing errors than others.ConclusionsImplementing a computerized prescribing system without comprehensive functionality and processes in place to ensure meaningful system use does not decrease medication errors. The authors offer targeted recommendations on improving computerized prescribing systems to prevent errors.
| S-EPMC3197998 | biostudies-literature
Project description:Objectives(1) Systematically assemble, analyse and synthesise published evidence on causes of prescribing error in children. (2) Present results to a multidisciplinary group of paediatric prescribing stakeholders to validate findings and establish how causative factors lead to errors in practice.DesignScoping review using Arksey and O'Malley's framework, including stakeholder consultation; qualitative evidence synthesis.MethodsWe followed the six scoping review stages. (1) Research question-the research question was 'What is known about causes of prescribing error in children?' (2) Search strategy-we searched MEDLINE, EMBASE, CINAHL (from inception to February 2018), grey literature and reference lists of included studies. (3) Article selection-all published evidence contributing information on the causes of prescribing error in children was eligible for inclusion. We included review articles as secondary evidence to broaden understanding. (4) Charting data-results were collated in a custom data charting form. (5) Reporting results-we summarised article characteristics, extracted causal evidence and thematically synthesised findings. (6) Stakeholder consultation-results were presented to a multidisciplinary focus group of six prescribing stakeholders to establish validity, relevance and mechanisms by which causes lead to errors in practice.Results68 articles were included. We identified six main causes of prescribing errors: children's fundamental differences led to individualised dosing and calculations; off-licence prescribing; medication formulations; communication with children; and experience working with children. Primary evidence clarifying causes was lacking.ConclusionsSpecific factors complicate prescribing for children and increase risk of errors. Primary research is needed to confirm and elaborate these causes of error. In the meantime, this review uses existing evidence to make provisional paediatric-specific recommendations for policy, practice and education.
| S-EPMC6701596 | biostudies-literature
Project description:OBJECTIVE:Clinicians using clinical decision support (CDS) to prescribe medications have an obligation to ensure that prescriptions are safe. One option is to verify the safety of prescriptions if there is uncertainty, for example, by using drug references. Supervisory control experiments in aviation and process control have associated errors, with reduced verification arising from overreliance on decision support. However, it is unknown whether this relationship extends to clinical decision-making. Therefore, we examine whether there is a relationship between verification behaviors and prescribing errors, with and without CDS medication alerts, and whether task complexity mediates this. METHODS:A total of 120 students in the final 2 years of a medical degree prescribed medicines for patient scenarios using a simulated electronic prescribing system. CDS (correct, incorrect, and no CDS) and task complexity (low and high) were varied. Outcomes were omission (missed prescribing errors) and commission errors (accepted false-positive alerts). Verification measures were access of drug references and view time percentage of task time. RESULTS:Failure to access references for medicines with prescribing errors increased omission errors with no CDS (high-complexity: ? 2(1)?=?12.716; p?<?0.001) and incorrect CDS (Fisher's exact; low-complexity: p?=?0.002; high-complexity: p?=?0.001). Failure to access references for false-positive alerts increased commission errors (low-complexity: ? 2(1)?=?16.673, p?<?0.001; high-complexity: ? 2(1)?=?18.690, p?<?0.001). Fewer participants accessed relevant references with incorrect CDS compared with no CDS (McNemar; low-complexity: p?<?0.001; high-complexity: p?<?0.001). Lower view time percentages increased omission (F(3, 361.914)?=?4.498; p?=?0.035) and commission errors (F(1, 346.223)?=?2.712; p?=?0.045). View time percentages were lower in CDS-assisted conditions compared with unassisted conditions (F(2, 335.743)?=?10.443; p?<?0.001). DISCUSSION:The presence of CDS reduced verification of prescription safety. When CDS was incorrect, reduced verification was associated with increased prescribing errors. CONCLUSION:CDS can be incorrect, and verification provides one mechanism to detect errors. System designers need to facilitate verification without increasing workload or eliminating the benefits of correct CDS.
| S-EPMC6353646 | biostudies-literature
Project description:BackgroundThe volitional help sheet (VHS) for self-harm equips people with a means of responding automatically to triggers for self-harm with coping strategies. Although there is some evidence of its efficacy, improving acceptability and making the intervention available in a web-based format may be crucial to increasing effectiveness and reach.ObjectiveThis study aims to use the Theoretical Framework of Acceptability (TFA) to explore the acceptability of the VHS, examine for whom and under what circumstances this intervention is more or less acceptable, and develop a series of recommendations for how the VHS can be used to support people in reducing repeat self-harm.MethodsWe explored acceptability in two phases. First, our patient and public involvement partners evaluated the original VHS from a lived experience perspective, which was subsequently translated into a web-based format. Second, a representative sample of adults in the United Kingdom who had previously self-harmed were recruited via a YouGov survey (N=514) and were asked to rate the acceptability of the VHS based on the seven constructs of the TFA, namely, affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy. Data were analyzed using descriptive statistics, one-tailed t tests, and binary logistic regression. A directed content analysis approach was used to analyze qualitative data.ResultsParticipants in the web-based survey rated the VHS as positive (affective attitude; t457=4.72; P<.001); were confident using it (self-efficacy; t457=9.54; P<.001); felt they did not have to give up any benefits, profits, or values when using it (opportunity costs; t439=-15.51; P<.001); understood it and how it worked (intervention coherence; t464=11.90; P<.001); and were confident that it would achieve its purpose (perceived effectiveness; t466=2.04; P=.04). The TFA domain burden appeared to be an important indicator of acceptability. Lower levels of perceived burden when using the VHS tool were more prevalent among younger adults aged 18-24 years (OR 3.63, 95% CI 1.50-8.78), people of White ethnic background (OR 3.02, 95% CI 1.06-8.613), and people without a long-term health condition (OR 1.53, 95% CI 1.01-2.30). Perceived modifications to further improve acceptability included improved formatting (burden), the feature to add new situations and responses or amend existing ones (ethicality), and clearer instructions and further detail about the purpose of the VHS (intervention coherence).ConclusionsOur findings show high levels of acceptability among some people who have previously self-harmed, particularly among younger adults, people of White ethnic backgrounds, and people without long-term health conditions. Future research should aim to improve acceptability among older adults, people from minority ethnic groups, and people with long-term health conditions.
| S-EPMC8479604 | biostudies-literature
Project description:BackgroundGrowing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans.Methods and findingsSeven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review.ConclusionsTo our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published.Protocol registrationPROSPERO CRD42017067514.
| S-EPMC6559631 | biostudies-literature
Project description:Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis.Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices.To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children.In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%.FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children.
| S-EPMC3533113 | biostudies-literature
Project description:BackgroundNeonatal hypernatremic dehydration is prevented by daily neonatal weight monitoring. We aim to provide evidence-based support of this universally promoted weighing policy and to establish the most crucial days of weighing.MethodsWeight measurements of 2,359 healthy newborns and of 271 newborns with clinical hypernatremic dehydration were used within the first seven days of life to simulate various weighting policies to prevent hypernatremic dehydration; its sensitivity, specificity and positive predictive value (PPV) of these policies were calculated. Various referral criteria were also evaluated.ResultsA policy of daily weighing with a cut-off value of -2.5 Standard Deviation Score (SDS) on the growth chart for weight loss, had a 97.6% sensitivity, 97.6% specificity and a PPV of 2.80%. Weighing at birth and only at days two, four and seven with the same -2.5 SDS cut-off, resulted in 97.3% sensitivity, 98.5% specificity and a PPV of 4.43%.ConclusionA weighing policy with measurements restricted to birth and day two, four and seven applying the -2.5 SDS cut-off seems an optimal policy to detect hypernatremic dehydration. Therefore we recommend to preferably weigh newborns at least on day two (i.e. ~48h), four and seven, and refer them to clinical pediatric care if their weight loss increases below -2.5 SDS. We also suggest lactation support for the mother, full clinical assessment of the infant and weighing again the following day in all newborns reaching a weight loss below -2.0 SDS.
| S-EPMC5172525 | biostudies-literature
Project description:BackgroundPrescribing errors are common. It has been suggested that the severity as well as the frequency of errors should be assessed when measuring prescribing error rates. This would provide more clinically relevant information, and allow more complete evaluation of the effectiveness of interventions designed to reduce errors.ObjectiveThe objective of this systematic review was to describe the tools used to assess prescribing error severity in studies reporting hospital prescribing error rates.Data sourcesThe following databases were searched: MEDLINE, EMBASE, International Pharmaceutical Abstracts, and CINAHL (January 1985-January 2013).Study selectionWe included studies that reported the detection and rate of prescribing errors in prescriptions for adult and/or pediatric hospital inpatients, or elaborated on the properties of severity assessment tools used by these studies. Studies not published in English, or that evaluated errors for only one disease or drug class, one route of administration, or one type of prescribing error, were excluded, as were letters and conference abstracts. One reviewer screened all abstracts and obtained complete articles. A second reviewer assessed 10 % of all abstracts and complete articles to check reliability of the screening process.AppraisalTools were appraised for country and method of development, whether the tool assessed actual or potential harm, levels of severity assessed, and results of any validity and reliability studies.ResultsFifty-seven percent of 107 studies measuring prescribing error rates included an assessment of severity. Forty tools were identified that assessed severity, only two of which had acceptable reliability and validity. In general, little information was given on the method of development or ease of use of the tools, although one tool required four reviewers and was thus potentially time consuming.LimitationsThe review was limited to studies written in English. One of the review authors was also the author of one of the tools, giving a potential source of bias.ConclusionA wide range of severity assessment tools are used in the literature. Developing a basis of comparison between tools would potentially be helpful in comparing findings across studies. There is a potential need to establish a less time-consuming method of measuring severity of prescribing error, with acceptable international reliability and validity.
| S-EPMC3834169 | biostudies-literature