A Hopeful Pharmacist-Led Educational Program to Reduce Prescription Errors

by Spencer Harris, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of:  Gursanscky J, Young J, Griffett K, Liew D, Smallwood D. Benefit of targeted, pharmacist-led education for junior doctors in reducing prescription writing errors - a controlled trial. Journal of Pharmacy Practice and Research. 2018;48(1):26–35.

Writing a safe and properly-formatted prescription is no easy task. Not only does the prescriber need to include the patient’s name, date of birth or address, the date of the writing, the name of the drug, the dose, the dosage form, the instructions on how to take it, the quantity, the number of refills, and the signature of the authorizing provider but the prescriber must write a prescription that is safe for the patient. Factor in the multitude of patients a physician sees, the innumerable questions that she receives, the monotony of writing dozens of prescriptions every day, and many other variables that add stress on her shoulders, it's understandable there will be an error here and there. While understandable, it is not something that can be accepted or overlooked. Each year, according to the FDA’s Wedwatch website, more than one hundred thousand reports about medication errors are documented. A subset of these reports are related to errors in prescribing errors, both in the sense of missing information and prescribing inappropriate therapy.  These errors affect patient health outcomes; this is inexcusable. I have witnessed these errors firsthand, as I am sure nearly every person who has worked in a pharmacy has.

Educational programs might be one way to address this problem. But an educational program must be efficient and compatible with the constant bustle of healthcare, where there is no time to waste. It is for this reason that I read the study by Gursanscky and his colleagues from Monash University in Australia with high hopes.

The investigators implemented a pharmacist-led approach to teaching junior physicians (who write a notably large proportion of prescriptions in teaching hospitals) about prescription writing.  They compared this approach to an online education program (based on the National Inpatient Medication Chart Training course) and to a control group that did not receive any additional instruction. The study was a cluster-randomized trial that enrolled all junior doctors in the general medical units at an Australian tertiary hospital (twelve interns and four registrars). The junior physicians were divided equally into four person-groups who were randomly assigned to either the pharmacist-led intervention (one group), the e-learning intervention (one group), or the control arm (two groups).

The pharmacist-led intervention consisted of three very brief (10-minute) sessions per week for four weeks.  During these sessions, a clinical pharmacist discussed types of errors, their frequency, and severity. Over the four weeks, the pharmacist discussed each error type, why it was unsafe, its consequences, and how to avoid it. Following each tutorial, the pharmacist addressed participant questions. A full report on the intervention can be found in the original study.

Data was collected for three weeks before the intervention and for four weeks during the intervention. The data collected was the prescription error rate among all groups. An error was defined as a prescription that had incomplete patient or prescriber details or which was “illegible, incomplete, or incorrect.” The error rates were then compared using a Chi-square analysis for the pre- and post-intervention periods.

The results (n= 9,657 prescriptions analyzed) showed that the pharmacist-led group had a significantly lower rate of errors in the post-intervention period. Interestingly, the error rates in both the control group and the e-learning group increased significantly in the post-intervention period.

Table 1: Rate of Errors per Total Orders Before and After the Intervention Period

	Control	E-learning	Pharmacist-led
Pre-intervention	0.49	0.58	0.58
Post-intervention	0.59	0.63	0.37
p-value	<0.001	0.025	<0.001

This study addresses a real-world problem that negatively impacts patients and places a substantial burden on the healthcare system. Additionally, the study clearly describes the design of the educational intervention and outcome measures (e.g. the prescription writing error and its methods of data collection).  The number of prescriptions that were analyzed over the course of the study is very large (n=9,657). With that large of a sample, it is likely that the measured error rate is small but there is always the possibility of bias in the selection process. This study also has some flaws that can leave it weak in the eyes of reasonable readers. Specifically, the sample size of providers is small with only sixteen physicians, four per group.  The study duration was relatively short — approximately two months. These shortcomings may have led to the odd and significant increase in the error rate among the e-learning group and control group. Why would a course designed by professionals to instruct providers on how to write prescriptions result in a higher prescription error rate? Of course, the e-learning course could be poorly designed in some way, but I believe that the more likely reason is there was a small number of participants in the group.  Thus the changes in error rates observed in the control and pharmacist-led intervention groups might be due to chance as well.

Personally, I believe a pharmacist-led approach can and should result in a lower error rate, but I believe that this study must be replicated on a larger scale before any conclusions can be made about the effectiveness of this approach. None-the-less, the study is still relevant. The reason is simple; there are preventable medication errors being made all over the world and they lead to problems that directly affect patients. Until this problem is solved, we should be looking for answers and taking action to find good practices for reducing the errors. While this study is not of the highest quality, the intervention is simple and practical to implement.

Therefore, I urge those who are involved in the training of prescribers to use this study as a template to provide pharmacist-led instruction on prescription-writing. A successful program should include frequent but brief tutorials with an opportunity to ask questions. We must actively make efforts to provide our patients with the high-quality healthcare that they deserve.

References

1. Gursanscky J, Young J, Griffett K, Liew D, Smallwood D. Benefit of targeted, pharmacist-led education for junior doctors in reducing prescription writing errors - a controlled trial. Journal of Pharmacy Practice and Research. 2018; 48(1):26–35.
2. Working to Reduce Medication Errors [Internet]. U.S. Food and Drug Administration. FDA; 2019.  Accessed October 23, 2020.