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.