Pharmacist-Led Educational Interventions Decrease Prescribing Errors

by Michaela Shoup, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Winder MB, Johnson JL, Planas LG, Crosby KM, Gildon BL, Oberst-Walsh LA. Pharmacist-led educational and error notification interventions on prescribing errors in family medicine clinic. J Am Pharm Assoc 2015; 55(3): 238-45. doi: 10.1331/JAPhA.2015.14130

Medication errors are a serious problem in the United States’ healthcare system. Studies have shown that medical errors account for over 250,000 deaths every year, making medical errors the third leading cause of death in the United States. Reducing prescribing errors is a vital step in decreasing the number of patients harmed and improving outcomes.  Another issue plaguing healthcare in the United States today is the lack of available positions for pharmacists and the failure of many healthcare professionals to fully realize the value and knowledge pharmacists can bring to the healthcare team. In this study to evaluate the impact of pharmacist-led educational and error notification interventions on prescribing errors in a family medicine clinic, the researchers created a program that addresses both of these issues at once. This study showed that physicians made fewer errors when writing prescriptions for pediatric patients after participating in a pharmacist-led educational program.¹

This 14-month study took place in an outpatient academic family medical clinic affiliated with the University of Oklahoma. Of the twenty-four resident physicians at the clinic, fourteen residents participated in the educational program and their prescribing habits were longitudinally assessed. The study was composed of four phases: preintervention error assessment, educational intervention, error notification intervention, and postintervention error assessment. First, prescriptions written by the resident physicians were assessed for the number and types of errors they contained, including missing information such as date, unclear directions, or incorrect dose. The researchers used multiple instructional methods to educate the residents. First, they employed a pharmacist-led lecture with active learning activities in which residents learned about the most common types of prescription errors, how to effectively use an electronic medical record (EMR), and the necessary elements of a prescription. In the error notification intervention, pharmacists used a feedback system for a period of three months to help the residents see what strengths they had and what areas they should improve. As a part of this feedback system, residents received notification of errors in prescriptions they had written and were offered assistance from clinical pharmacists. Residents also received a weekly newsletter summarizing the most common errors made and providing recommendations for improvement. The feedback and audit system likely played a vital role in training these physicians— feedback enables learners to gain perspective from others on how they can change and improve. A year after the initial data collection began, the postintervention assessment was conducted. A new set of prescriptions written after the conclusion of the program was assessed for errors to see if and how the residents’ prescribing practices had improved.

The results showed that the rate of prescribing errors was 23% lower during the postintervention period when compared to the preintervention period.  However, this difference was not statistically significant when controlling for time. The lack of statistical significance could be due to each resident having different baseline knowledge and experience. For example, the more experienced residents may not have benefitted from the program as much as the less experienced physicians, and this may have diminished the impact of the educational intervention. In addition to the primary analysis, the researchers analyzed the error rates of residents who participated in the educational program compared to those who did not. Controlling for time, pediatric prescription error rates were 36% lower among physicians who participated in the educational intervention versus those who did not participate. This difference was statistically significant, and the authors concluded that the prescribing of pediatric medications was positively impacted by the program.

This study aimed to show the value of pharmacists’ knowledge and expertise.  While the results are promising, the Hawthorne effect could have played a role in the results — physicians could have changed their prescribing habits simply because they knew they were being evaluated, possibly leading to a lower error rate than might have been seen had the physicians been unaware their performance was being evaluated. The study group was diverse—it was comprised of PGY1 through PGY4 residents.  So each physician had a different level of experience. The residents received uniform education and feedback, which is a strength of the study. However, we do not know which of the individual components of the program – the lecture, audit and feedback, or the newsletter – had the most impact.  Indeed, we don’t know if the residents actually read the newsletter.

Other studies have been conducted to show that pharmacist-led education positively impacts prescribing practices and, ultimately, the quality-of-care patients receive. The DEPRESCRIBE study evaluated the effect of a pharmacist-led educational invention on discontinuation of medications that were inappropriate for patients aged 65 and older (based on Beers criteria).² Pharmacists in this study provided education to patients (supplemented by educational brochures) and made pharmacological recommendations to their providers regarding medications that may be more harmful than beneficial in older adults. Over 40% of the potentially harmful medications were discontinued by the physicians that were educated by the pharmacist.  This substantially greater than the discontinuation rates (12%) observed when the patients and physicians were not educated.

In a time when an alarming number of patients are being by less-than-optimal medication regimens and when job positions for pharmacists are not as plentiful as they once were, pharmacists must use their training to improve patient outcomes and make their value evident. Pharmacists are capable of educating both their coworkers and patients to decrease error rates, provide high-quality patient care, and improve health outcomes. Pharmacists are in the ideal position to share their knowledge and expertise to benefit patients, colleagues, and the profession of pharmacy. 

References:

1. Winder MB, Johnson JL, Planas LG, Crosby KM, Gildon BL, and Oberst-Walsh LA. Impact of pharmacist-led educational and error notification interventions on prescribing errors in a family medicine clinic. J Am Pharm Assoc 2015; 55(3): 238-245. doi:10.1331/japha.2015.14130
2. Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA. 2018; 320(18): 1889-1898. doi: 10.1001/jama.2018.16131.

Prescribing Education for Medical Students

by Danielle McGrew, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Newby DA, Stokes B, Smith AJ. A pilot study of a pharmacist-led prescribing program for final-year medical students. BMC Med Educ. 2019 Feb 12;19(1):54. doi: 10.1186/s12909-019-1486-1 

I love to find articles in the literature focused on ways pharmacists have implemented a program, educated others, or proven their worth while working on an interprofessional team. So, when I came across an article about a pharmacist-led educational program that benefited patients and prescribers alike, I was immediately intrigued.  The purpose of this study was to improve prescribing confidence and skills and to improve medical students’ understanding of the role pharmacists can play in the management of patients. It is known that prescribing medications is one of the intimidating tasks for medical students as they transition to becoming licensed physicians. One study found that recent medical school graduates did not feel prepared for prescribing in clinical practice, which they attributed to a lack of opportunities to develop the skill-based, applied aspects of prescribing.¹  Other studies have shown that medical interns often prescribe inappropriately for many common conditions.² Thus, there is a need for more training and practice opportunities for medical students to prepare them for clinical practice.

In this study conducted in Australia, all final-year medical students at three tertiary hospitals were invited to take part in an eight-week prescribing training program. The program consisted of three instructional strategies: prescribing and calculation tutorials, weekly feedback from a pharmacist regarding prescribing, and one afternoon spent in the pharmacy to learn about and observe the dispensing process. The tutorials involved allowing the students to practice either selecting and prescribing medications or calculating and prescribing a dose of a medication based on a case scenario representing the most common conditions faced by junior doctors. The common conditions included stroke prevention (anticoagulation therapy), diabetes, pain management, constipation, nausea and vomiting, asthma, and hypertension. Confidence and appropriateness of prescribing were measured upon completion of the tutorials on week one and week eight. Confidence in a variety of prescribing areas was assessed using a confidence scale adapted from a questionnaire developed by the TOPDOC study team to rate junior doctor confidence.³ The tutorials covered such topics as selecting a medication for a condition, writing a prescription order for both inpatients and outpatients, taking a medication history, identifying potential drug interactions and adverse events, monitoring effectiveness, and planning discharge medications.  To assess the appropriateness of prescribing, the students completed a prescribing exercise based on a clinical scenario. Blinded to what student was completing the exercise and to whether it was a pre- or post-assessment, a clinical pharmacist and clinical pharmacologist assessed the appropriateness of each prescription using a previously validated scale. Additionally, students provided feedback about the impact of the program at the completion of the program by participating in focus groups and completing a questionnaire. Pre- and post-program assessments were examined using permutation tests, which assesses whether two distributions are significantly different from each other without making any assumptions about the shape of the distributions.

Twenty-three students completing their rotations at three hospital sites agreed to participate, with only 16 participating in most or all of the required activities and taking the pre- and post-course questionnaires and assessments. Results showed a significant increase in confidence across all areas of prescribing skills assessed. At baseline, a majority of students rated themselves as ‘not confident’ or ‘satisfactory but lacking confidence’ in each area, but upon completion of the program none of the students rated themselves as ‘not confident’ in any area, with the exception of one student that rated him/herself as ‘not confident’ in writing an outpatient prescription. The most noteworthy improvement was found in writing inpatient prescriptions – after the program, all students rated themselves as ‘confident in most cases but would like more experience’ or ‘fully confident in most cases.’  None of the students rated themselves ‘fully confident’ at baseline. Students were most confident in writing prescriptions for medications related to the disease states discussed in the tutorials.

There was a small and non-significant improvement in the appropriateness of the students’ prescribing from baseline to week eight. However, it is important to note is that none of the students’ prescriptions were rated ‘inappropriate and potentially harmful’ after finishing the prescribing program. Student feedback was uniformly positive, with students agreeing or strongly agreeing to statements about the practical aspects of prescription writing, therapeutic appropriateness, and calculations aspects of the program.  Also, students indicated that the program helped to prepare them for their intern year. The focus group sessions revealed that students most valued the practice and immediate feedback they received.  Moreover, they learned about the support pharmacists can provide to them as prescribers. Negative comments centered on the difficulty of fitting the program into their schedule during demanding clinical rotations.

I thought that this was a good study to evaluate how influential a prescribing program may be on medical student’s knowledge and confidence in writing prescriptions. One major weakness was the small sample size. Larger studies would be needed to quantify the impact of such a program on prescribing appropriateness. Given the small sample size, assessing changes in student confidence was the most appropriate thing to measure. A major strength of the program was the immediate feedback that was provided to the medical students. I also think that the use of focus groups to gather feedback was really important, especially since this was a pilot program.

Other studies focusing on prescribing education for medical students have shown positive results as well. Medical students participating in a ‘near-peer’ prescribing education program reported increased confidence in their prescribing knowledge and skills after attending the tutorials.⁴ Similarly, results from medical students participating in a teaching program on practical prescribing showed that their knowledge of pharmacotherapy, drug information, and prescribing skills was significantly improved.⁵

Educators should pay attention to this pilot study it appears to be a well-designed educational program intended to improve the confidence and skills of future physicians. In particular, I would recommend educators replicate the content of the tutorials and providing immediate feedback. In this instance, medical students are getting to practice real-life scenarios using clinical cases. I believe the best practices of instructional design are being upheld. The material is presented in the form of tutorials, the instructor tests the student’s knowledge on what has been taught through the clinical cases, and students can reflect on their performance based on immediate feedback. Educators should take into account the challenges of offering this program due to time constraints during demanding clinical rotations. My recommendation would be to initiate the prescribing program earlier in the medical school curriculum (perhaps during an early practice experience) and to reduce the weekly workload required. One medical school has already implemented “Safe Prescribing Teaching” earlier in their curriculum, resulting in students feeling remarkably more confident in prescribing situations.⁶ This strategy allows students to revisit and build on the knowledge they learn each week and would likely yield even better results.

 References

1. Rothwell C, Burford B, Morrison J, et al. Junior doctors prescribing: enhancing their learning in practice. Br J Clin Pharmacol. 2012 Feb;73(2):194-202. doi: 10.1111/j.1365-2125.2011.04061.x. PMID: 21752067; PMCID: PMC3269578.
2. Pearson S, Smith AJ, Rolfe IE, Moulds RF, Shenfield GM. Intern Prescribing for Common Clinical Conditions. Adv Health Sci Educ Theory Pract. 2000;5(2):141-150. doi: 10.1023/A
3. George JT, McGrane DJ, Warriner D, et al; TOPDOC Study Team. Protocol for a national audit on self-reported confidence levels, training requirements and current practice among trainee doctors in the UK: the Trainees Own Perception of Delivery of Care in Diabetes (TOPDOC) Study. BMC Med Educ. 2010 Jul 27;10:54. doi: 10.1186/1472-6920-10-54.
4. Gibson KR, Qureshi ZU, Ross MT, Maxwell SR. Junior doctor-led 'near-peer' prescribing education for medical students. Br J Clin Pharmacol. 2014 Jan;77(1):122-9. doi: 10.1111/bcp.12147. PMID: 23617320; PMCID: PMC3895353.
5. Javadi MR, Khezrian M, Sadeghi A, Hajimiri SH, Eslami K. An Interprofessional Collaboration between Medicine and Pharmacy Schools: Designing and Evaluating a Teaching Program on Practical Prescribing. J Res Pharm Pract. 2017 Jul-Sep;6(3):178-181. doi: 10.4103/jrpp.JRPP_17_16. PMID: 29026844; PMCID: PMC5632939.
6. Lloyd N. Pharmacist-led teaching as a longitudinal theme for medical school curriculums - a solution for reducing prescribing errors in junior doctors? BMC Med Educ. 2019 May 29;19(1):173. doi: 10.1186/s12909-019-1632-9.