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Does feedback to prescribers help to reduce prescription errors?

| March 12, 2015

Does feedback to prescribers help to reduce prescription errors?

Literature Review

AIM: The aim of this literature review is to determine from previous studies the effectiveness of feedback to doctors in reducing the rate of future prescribing errors and to determine if there are any studies that have been carried out to improve method of feedback.

Objectives: The objectives of this literature review are to identify and evaluate the relevant studies and discuss the following:
• The methods used in the studies.
• How the impact of the feedback was measured and how the data was analysed.
• The pharmacist’s role in minimizing prescribing errors.
• How feedback was provided, and what the advantages and disadvantages were
• Whether feedback was constructive and valued by the recipients.
Search Strategies
Relevant literature was identified using the electronic database PubMed. Mesh terms were used. The question was broken down to use the key words such as: ((“Physicians”[Mesh]) AND “Pharmacists”[Mesh]) AND “Feedback”[Mesh]. This search returned only 8 results out of which two relevant articles were used for the review. The search term (“Electronic Prescribing”[Majr]) AND “Pharmacists”[Mesh] returned 11 results. The search for the term ‘medication errors [MeSH]’ AND Pharmacists”[Mesh]) resulted in 314 results. These articles were browsed through and some relevant articles were sourced by going through the related citations.termyur

Literature review
Prescription errors are the most common among medical errors. The UK department of Health has defined prescription errors as “. . .any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer.” (Eisenhut et al, 2011). These errors maybe due to transcription mistakes, faulty dosage or erroneous medical diagnosis. In many cases prescription errors occur due to inadequate knowledge of the history of the patient, previous treatment and previous allergies, etc. Furthermore complex procedures and the lack of clear communication between the physicians and nursing staff have also been identified as contributing factors for prescription errors. This literature review will focus on the effectiveness of prescription feedback as an important process aimed at reducing or eliminating prescribing errors.

Some Early Studies
The effectiveness of prescription feedback had been long studied in hospital settings. One of the earliest such studies was conducted by Pozen and Gloger (1976). This study focused on the impact of administrative feedback on the prescribing patterns of the hospital doctors. The physicians were divided between three groups – control, intensive education and the groups receiving administrative feedback. The researchers utilized a ‘drug performance index’ to evaluate the under prescription, over prescription or mis-prescription by the house doctors. It was observed that administrative feedback led to a 64% reduction in the drug prescription index. Another early study by Grimm et al. (1975) studied the effectiveness of a feedback protocol in reducing the prescription of antibiotics for a viral infection such as pharyngitis. The feedback was in the form of weekly audits and individualized report sent by the medical director of the hospital. This feedback protocol resulted in a drop of antibiotic prescription for patients complaining of sore throat from 56% to 18% suggesting that prescription feedbacks had a positive influence in reducing overuse and wrong use of drugs. Groves (1985) observed that a computer based prescription drug review and feedback system resulted in changing prescribing behavior in 50% of the cases indicating that prescription feedbacks have a strong positive effect and help in better compliance with prevailing national guidelines and prescription protocols. (Soumerai et.al 2005)

Recent Studies

Eisenhut et al. (2011) is one recent research that studied methods of avoiding prescription errors in a pediatric clinical setting. The study included two main components. First was a month long auditing of the prescribing errors by pediatricians based on review of drug charts by pharmacists. This enabled the study authors to note down incorrect prescriptions and analyze them further for the type of errors including major ones such as prescription of drugs that the patient is allergic to, dosage errors etc. As the second stage of the study, the researchers asked the pediatricians who had a high level of errors in the preliminary auditing to complete 5 tasks related to prescribing. These included transcribing prescriptions with deliberate errors, two prescribing tasks and two intravenous drugs prescriptions, the dosage requirements of which had to be carefully calibrated using the British National Formulary for children. The tasks were then assessed by a pharmacist and a senior pediatrician. The pharmacist then personally emailed a detailed feedback based on the assessment to all the study participants. The prescriptions of all the pediatricians who had serious errors in the test tasks were carefully monitored by a senior pediatrician until they passed out successfully in the next assessment.

A re-auditing was subsequently done to assess the effectiveness of feedback in preventing prescription errors and a total of 16 physicians participated. The researchers noticed that in the tasks related to dosage and prescribing intravenous drugs there were significant improvements. All the 16 physicians successfully cleared the second assessment for the intravenous drug formulations. Dosage errors which were 7 in the first assessment now reduced to 4 in the assessment after the feedback. Even the allergy section of the prescription chart which was incomplete in 8 patient charts during the first assessment showed a marked improvement with just 1 chart lacking completion in the final assessment. (P = 0.005). The authors concluded that regular assessment and pharmacist feedback had a positive impact on reducing physician prescription errors. (Eisenhut et al, 2011)
Another older and well known study by the Norwegian Drug education Project (DEP) focused on the usefulness of education and feedback on the improvement of physician prescribing patterns. This study by Lagerlov et.al (2000) included a total of 199 general practitioners who were split between 32 groups each comprising 4 to 8 GP’s. The prescription patterns for Asthma and urinary tract infections were the focus of this study. All the participants of the study took part in two meetings that were also attended by a local pharmacist and two project coordinators. In the meetings the GP’s were asked to describe the quality criteria for their prescriptions which were later compared with the national guidelines for prescriptions for asthma and UTI. The researchers used the prescriptions of the participating GP’s over the last one year as the basis for their feedback. The researchers felt that the comparison of the prescription feedback with the self described quality criteria of the GP’s would provide them with a better understanding of the acceptable treatment standards and the discrepancies in their own prescribing patterns.

To measure the impact of feedback on the prescribing behavior, the researchers compared the prescriptions of the participants over the next one year with that of the base line data. Prior to the intervention, the percentage of appropriately treated patients for asthma was 28% while it was 27% for UTI patients. It was found that the mean proportion of acceptable treatments prescribed in both the groups improved significantly post feedback period with the asthma group showing a 21% improvement in treatment standards while the UTI group registered a 108% improvement. This huge and statistically significant difference in proportions between the acceptably treated patients prior to and post feedback clearly suggests that prescription feedback to general practitioners has a positive effect in reducing the prescription errors and helps to improve the overall standard of care. Overall, the researchers of this study observed that providing prescription feedback was a powerful factor that influenced positive behavioral changes in practitioners. (Lagerlov et.al 2000)
Gommans et.al (2008) is another recent study that evaluated the effect of serial audits and feedback interventions on the prescribing behavior of physicians in a hospital setting. For this study the researchers audited the prescription charts of a hospital between 1998 and 2007. Compared to standard guidelines these prescription charts were lacking pertinent details. For instance, almost 58% of the charts lacked prescriber identification, 14% lacked information related to route of administration, 11% were missing out on dosage details, etc. Medication alerts were included only in 53% of the charts and patient identification was missing in 8% of the charts. However, by the end of the study period in 2007, the impact of serial audits was already beginning to show. The intervention included feedback of the audit results. This resulted in a marked improvement as gathered from the changes to the prescription chart entries. Subsequent audits showed that there was 100% patient identification, 97% drug route information, 99% with dosage details. The improved medical charts are clearly suggestive of a better standard of medical care that is more in adherence with the national protocol. This study again attests our inference that prescription feedbacks based on periodic audits has a positive influence on improving the prescribing behavior of physicians. (Gommans et.al, 2008)

One Australian study by Nishtala et.al (2011) studied the impact of pharmacist recommendation and physician implementation of the same in improving drug related problems (DRP) in Australian aged care settings. For this retrospective study, the authors conducted 500 randomly selected medical reviews from 62 aged care centers in Australia. These reviews were performed by pharmacists and over 1433 cases of DRP were identified. More than 75% of these DRP’s were related to cardiovascular and respiratory drug prescriptions. These review reports were then written by a GP and sent as feedback to the respective physicians. Overall 480 of the 500 patients had DRP’s. The feedback acceptance was 72.5% (95% CI; 70.2, 74.8) while the subsequent implementation of the recommendations in the feedback was 58.1% (95% CI; 55.5, 60.6). It is evident from this study that there is a high prevalence of drug related problems, especially among the residents of aged care homes. Age might increase the risk for adverse drug interactions and hence prescriptions for old age people should be carefully exercised. This study highlights the potentially vital role of the pharmacist in providing relevant feedbacks that could help physicians avoid the dangers of inappropriate prescriptions in this vulnerable population. (Nishtala et.al, 2011)

Another European study analyzed the effect of feedback on prescribing behavior in outpatient settings of 17 clinics in a Swedish city. As a control group the researchers included clinics from an independent university. Interactive group discussions were organized to discuss the prevailing prescription patterns in the clinics of the experimental group. This information was obtained from the pharmacist dispensing data. In these meetings the general practitioners discussed the prescription patterns relating to general diseases against the regionally indicated standards. Based on these interactions clinic level plans were developed to facilitate more adherence to the established standards. The effectiveness of these clinic level feedbacks were then measured by comparing post intervention prescription data with the base line prescription patterns. From this research the study authors inferred the following results. It was found that the adherence to the use of the recommended drug groups increased by 2.8% in the intervention group while it was only 0.8% in the control group. Furthermore, for 8 out of 11 agreed upon areas of improvement, the positive changes in the intervention group was much better than in the control group of hospitals. Overall, the physicians in the intervention group were satisfied with the clarity of the feedback. This study confirms the positive potential of feedback in influencing physician prescribing behavior and adherence to existing medical standards of prescription.
(Wettermark b, 2005)

Bergkvist (2009) focused on the impact of pharmacist feedback of the discharge summary prior to the discharge of the patient and its impact on reducing medical errors in the transition of the patient from the hospital to the primary care clinics. The researchers recruited 52 patients from a hospital ward for the intervention group while 63 other patients from the same ward were selected for the control group. Clinical pharmacists verified the discharge summary of all the intervention group patients and their feedback was passed on to the physician. This allowed for drug reconciliation and eliminated the errors in transition from the hospital to the patient’s primary care setting. The study authors found that this intervention, based on the discharge summary feedback, had an overall beneficial effect. In particular, the medication errors for patients in the intervention group dropped by 45%. (P = 0.012). Furthermore, the intervention group also improved significantly with 73.1% of the patients in this group showing no medication errors while it was 63.5% in the control group. This study again attests to the research findings that feedback can improve prescription and decrease the instances of medical errors. (Bergkvist, 2009)

Physician Acceptance
One particular study assessed the acceptance of feedbacks by physicians. This study was conducted between February and May 2005. For this research ward pharmacists were asked to gather and record all prescription data for new orders once every fortnight from Feb to May 2005. During the observation period of 8 days a total of 4995 new medication orders were placed of which around 462 orders had errors. (95% confidence interval 8.5 -10.1%). Within the experimental period but on non data collection days, only a total of 8 prescription errors were reported. Pharmacists indicated that they would have reported 19 instances within the data collection period. Furthermore the detailed prescription error reports with graphical summaries were well accepted by the clinicians. This study reported that prescription error reports in the form of feedbacks were well tolerated by clinical specialists and it increases the error reporting on a day to day basis. The study also revealed that in the absence of a routine prescription feedback system there is a high prevalence of under reporting. Thus this study clearly indicates that a feedback system is not only effective but highly essential to improve the quality of medical care for patients. (Franklin et.al, 2007)

Trainee medical staff are prone to making medication errors. Thomas et.al (2008) studied the effectiveness of prescription audit and feedback in decreasing errors in an intensive care setting. For this purpose the researchers used ward education and prescription feedback in 3 monthly cycles for the trainee medical staff. During this time, monthly audits were conducted in the pre training, post training and a final audit period after 6 weeks. Comparing the proportion of prescription errors during these different periods of time helped the researchers assess the impact of the audits and the feedback. The researchers found a general decline in prescription error rates over the experimental period. The error percentage recorded for the pre training period was 25%, 19% , (one missing data) while that for the post training audit was 23%, 6%, 11%,and the final audit was 7%, 3%, 5% (p<0.0005)). It is clearly obvious from these data that the educational training followed by auditing and feedback had a positive impact in reducing the prescription errors from 25% in the pre training period to 7% in the final auditing period. Feedbacks definitely help physicians reduce their error rates. (Thomas et.al, 2008)
One recent study analyzed prescription errors occurring in a medical center with a computerized discharge system. This study by Qader et.al (2010) studied a 904 bed hospital in northwest England. The researchers used a computerized search of the medical ordering system over a four week period. Pharmacists were consulted in the next few days immediately following the data extraction. These pharmacists categorized the nature of the errors. A senior pharmacist further segregated the errors into either computer related errors (CRE) or prescription errors. Any serious errors were then discussed with the physician and corrections immediately effected. Over the 4 week study period involving 1038 patients, a total of 7920 medical errors were noticed. Overall, the prescription error rate was 8.4% (95% CI 7.8, 9.0 [n = 664/7920] Of these, 469 [74.4%]) errors were rated high in terms of their severity and pharmacist feedback and discussion with the physician was very important to avert any adverse medical event. This study again highlighted the high rates of prescription errors occurring during the discharge stage. Pharmacist’s feedback and interaction with the physician are found to be crucial in preventing any adverse drug events. Pharmacist documentation and error verification through quick cross checking with the medical professionals would drastically cut prescription errors and save patients from any harm before it could happen. (Quader et.al, 2010)
Conclusion
The economic and clinical impacts of inappropriate prescriptions are huge. Prescription feedback is an important interventional tool that helps in reducing preventable mortality and morbidity from adverse drug events caused by erroneous prescriptions. The research studies discussed above clearly highlight the positive role of pharmacist or other physician groups in providing vital feedbacks. These feedbacks not only help the general practitioner in keeping abreast with the latest developments in pharmacological science but also directly contribute to reducing instances of over prescribing, under prescribing and mis-prescribing. Email based feedbacks as well as multi disciplinary discussions were found to be effective in resolving discrepancies and avoiding future errors. Feedbacks definitely have a positive impact on the quality of prescriptions and they help improve the overall quality of medical care provision.

Bibliography
1) Michael Eisenhut, Blanche Sun, and Sarah Skinner, (Sep 2011), Reducing Prescribing errors in pediatric patients by assessment and feedback targeted at prescribers, ISRN Pediatrics, Volume 2011, Article ID 545681.

2) Bergkvist A, Midlöv P & Höglund P (Oct, 2009), Improved quality in the hospital discharge summary reduces medication errors –LIMM Landscrona integrated medicines management, Eur J Clin Pharmacol. 65(10):1037-46

3) Per Lagerløv, Mitchell Loeb, Marit Andrew, Per Hjortdahl (2000), Improving Doctors’ prescribing behavior through reflection on guidelines and prescription feedback: A randomized controlled study, Quality in Health Care 2000;9:159–165, viewed Nov 27th 2011, <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743532/pdf/v009p00159.pdf>
4) Abdel-Qader DH, Harper L, Cantrill JA, Tully MP (Nov 2010), Pharmacists’ interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital, Drug Saf. 33(11):1027-44.

5) Franklin BD, O’Grady K, & Paschalides C, et.al (Jun 2007), Providing feedback to hospital doctors about prescribing errors ; a pilot study, Pharm World Sci. 29(3):213-20

6) Wettermark B, Haglund K & Gustafsson LL et.al (Aug 2005), A study of adherence to drug recommendations by providing feedback of outpatient prescribing patterns to hospital specialists, Pharmacoepidemiol Drug Saf. 14(8):579-88.

7) Nishtala PS, McLachlan AJ, Bell JS & Chen TF, (Feb 2011), A retrospective study of drug related problems in Australian aged care homes: medication reviews involving pharmacists and general practitioners, J Eval Clin Pract. 17(1):97-103

8) Thomas AN, Boxall EM, Laha SK, (Oct 2008) An educational and audit tool to reduce prescribing error in intensive care, Qual Saf Health Care. 17(5):360-3.

9) Gommans J, McIntosh P, Bee S, Allan W. (2008), Improving the quality of written prescription in a general hospital: the influence of 10 years of serial audits and targeted interventions, Intern Med J. Apr; 38(4):243-8.

10) Stephen B Soumerai, Thomas j McLaughlin & Jerry Avorn, (2005) , Improving Drug Prescribing in Primary care: A critical analysis of the experimental literature, The Milbank Quarterly, Vol. 83, No. 4, pg 1-48, viewed Nov 17th 2011, <http://www.milbank.org/quarterly/830432soumerai.pdf

 

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