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REDUCING PRESCRIPTION ERRORS oN PSYCHIATRIC INPATIENT wARDS

Dr Alexis Bowers MRCPsych Specialist Registrar, General Adult Psychiatry, Hertfordshire Partnership NHS Foundation Trust.

Pnina Phillips Clinical Pharmacist for psychiatric services, St Albans City Hospital, Hertfordshire Partnership NHS Foundation Trust.

Dr Frances Burnett MRCPsych Consultant Psychiatrist, General Adult Psychiatry, Hertfordshire Partnership NHS Foundation Trust.

INTRODUCTION

The last decade has seen an increasing clinical awareness in the incidence of prescribing errors (Dean, et al 2002a). Numerous journals have published articles on themes around this topic; what constitutes a prescribing error (Dean, et al 2000), the incidence of prescribing errors (Maidment, et al 2006, Stubbs, et al 2006, Haw, et al 2005, Stubbs, et al 2004, Haw, et al 2003, Paton, et al 2003 and Grasso, et al 2003a) and also reasons for the occurrence of prescribing errors (Lesar, et al 2007, Dean, 2002b). North American research demonstrates prescribing errors in up to 2% of all medication orders in general medical wards, and harm is caused by this in up to 1% of inpatients (Dean, et al 2000).

In the UK, the NHS pays out around £400 million per year in the settlement of clinical negligence claims, 20% of which are due to errors in the use of prescribed drugs (Department of Health, 2000). In their White Paper, An Organisation with a Memory, the Department of Health have set a target for reducing the number of serious errors in the use of prescribed drugs by 40% by 2005. This paper proposed the introduction of a new national system for identifying patient safety incidents in healthcare. The National Patient Safety Agency (NPSA), which was founded in June 2001, gathers information about events involving the compromise of patient safety at local level within NHS organisations. The aim is to improve patient safety by using the information to develop and implement effective preventative measures throughout the NHS.

The lack of published reports about prescribing errors within psychiatry has been highlighted (Grasso, et al 2003b). Psychiatrists are responsible for prescribing psychotropic drugs, which can have potentially serious side effects if not monitored closely, and also prescribing medication for conditions outside of a psychiatrist’s usual remit.

There is limited, but worrying data outlining incidence of prescribing errors in psychiatry (a total of 579 errors were recorded in a month long survey of 12 British

Mental Health Trusts, 63 of which could have resulted in a serious outcome, Paton, et al 2003). Studies in general and psychiatric hospitals have suggested that pharmacists are effective at detecting and correcting prescribing errors (Stubbs, et al 2004, Dale, et al 2003 and Hawkey, et al 1990) but no study to date has evaluated the effect of an educational intervention in reducing prescribing errors.

The aim of this study is to report incidence of prescribing errors in a British psychiatric inpatient unit, and to see what effect audit and education has on future prescribing practices.

METHOD

A 23-point guideline for identifying prescribing errors was abridged from the research tool described in the paper, 'What is a prescribing error?” (Dean, et al 2000) Errors relating to intravenous infusions were removed from the original tool as this mode of treatment is not given on the ward.

The audit was carried out in an English general adult psychiatric in patient unit with 24 inpatient beds. The inpatient unit serves the city of St Albans and the surrounding villages. There are three consultant psychiatrists and their respective trainees providing medical cover for the ward patients as well as a Chief Pharmacist from St Albans City Hospital who reviews all in patient medication charts on a weekly basis. The in patient unit is located in a different part of town to the City Hospital.

In conjunction with St Albans City Hospital Pharmacy department, all prescription charts and discharge prescription forms were audited during the six week monitoring period between the 24th March 2003 and the 4th May 2003. Reporting was carried out independently on both sites by the author and the clinical pharmacist for psychiatric services at the St Albans City Hospital. Ward based auditing was done every Friday for the preceding week and the total number of prescription errors/orders noted. Pharmacy reporting was done prospectively when a discharge prescription was received and the total number of prescription errors/orders noted. The results of the initial audit were presented at two local academic meetings (carried out between the 5th May 2003 and 1st June 2003). Although this audit focuses on prescribing errors, to enhance overall patient safety nurses were invited to attend as they are involved in dispensing prescribed medication. Both presentations were identical and were targeted at psychiatrists and psychiatric nurses respectively. The pharmacist and those staff who were on nights were not present at the meetings. The lecture gave a broad overview of factors related to prescription errors and actual examples from all “error groups” were displayed to the staff. Anonymity was preserved throughout. Following the presentation, prescribing charts/discharge prescription forms were audited for a further six weeks (2nd June 2003 to 13th July 2003) to see what effect education had on prescribing practices. Staff were unaware that an audit was being undertaken, and there were no significant staff changes throughout the 12 week monitoring period. Ethical approval was not obtained for this audit.

RESULTS

Initial monitoring of prescription charts and discharge prescribing forms revealed a total of 93 (23%) prescribing errors. This was over the six-week period where 407 prescribing orders had been written. There were 14 (26%) discharge prescribing form errors from 53 orders and 79 (22%) inpatient errors from 354 medication orders. Following the academic meeting and subsequent re-audit of prescription Charts and discharge prescribing forms a total number of 66 (11%) prescribing errors were observed. This was out of a total number of 622 prescribing orders. There were 6(9%) discharge prescribing forms errors out of 76 medication orders, (Chi-square with continuity correction [df1] = 6.82, p = 0.009) and 60(11%) inpatient errors from 546 medication orders, (Chi-square with continuity correction [df1] =20.24, p = 0.0001). The chi-squared test was used to compare pre and post intervention error rates. During both monitoring periods no incident forms relating to prescription errors were completed by either medical or nursing staff. In addition there was no record of any patient being transferred to the off site general hospital formedical treatment resulting from a prescription error. A break down of these results can be viewed in Table 1.

	1st Audit	2nd Audit
Errors in Decision Making
Is the dose of a drug, with a narrow therapeutic index, likely to cause significant high levels	0	4
Is the dose of a drug, with a narrow therapeutic index, likely to cause significant low levels	0	0
Has the dose not been altered following steady state serum levels outside therapeutic range	0	0
Has the drug been continued following an adverse drug reaction	0	0
Prescribing two drugs for the same indication when only one of the drugs is necessary*	1	0
Is it a sub-therapeutic dose	0	0
Is it inappropriate for the patients renal function	0	0
Is there a significant drug interaction	0	0
Has the patient got an allergy to the drug	0	0
Prescribing a drug for a patient for whom as a result of a co-existing clinical condition that drug is contra-indicated	3	0
Essential Information – Errors in Prescribing Writing
Has a drug, dose or route that is not intended been prescribed	0	0
Have abbreviations or non-standardised nomenclature been used	0	0
Has the prescribing been written illegibly	3	0
Writing an ambiguous medication order	10	3
Prescribing one tablet of a drug that is available in more than one strength tablet	1	6
Omission of a route of admission when the drug can be given by more than one route	3	0
Omission of a prescribers signature (initiation and termination of order)	69	52
Essential Information – Transcription Error
Writing ‘mg’ instead of ‘mcg’	1	0
Writing a prescribing for discharge medication that unintentionally deviates from the medication prescribed on the inpatient drug chart	2	0
Has there been a drug not prescribed from pre-admission	0	0
Has there been a drug incorrectly prescribed from preadmission	0	0
Has there been a GP error continued	0	0
Has a transcription error occurred when rewriting a chart	0	1

Table 1 – Prescribing error situations (Abridged from ‘What is a prescribing error’ (Dean, et al 2000). Prescribings of two antipsychotics in cross-tapering/adjunctive treatment were not included.*Prescribings of two antidepressants in cross-tapering/adjunctive treatment were not included.

DISCUSSION

Prescribing errors in this English psychiatric inpatient unit (231 errors per 1000 medication orders) are clearly in excess of those documented in general medical inpatient ward settings (3.99 errors per 1000 medication orders, Lesar, et al 1997). This bolsters previously reported data that suggest a potentially serious error is likely to occur on a weekly basis in an average trust (Paton, et al 2003). Our data suggests that the majority of errors that occur do so in the ‘errors in prescription writing’ process (Dean, et al 2000). These can be substantially reduced by adhering to prescribing chart guidelines: using clearly written text, inserting the dose against each administration time, inserting the route of administration and cancel clearly by crossing through, dating and initialling when any change is made and write a new prescription.

An example of a prescribing error included in this audit.

An anticholinergic medication was prescribed by a resident psychiatrist, dispensed by the pharmacist and administered to the patient without the psychiatrist signing or d ating the order.

Reason developed a model of accident causation (Reason, 1990)

LATENT CONDITIONS

Increased training of medical students in (psycho) pharmacology and practical prescribing advice. (Grasso, et al 2003b)

Creating a more open culture in which errors are openly discussed and reflected upon without fears of humiliation or reprisal (Department of Health, 2000)

ERROR PRODUCING CONDITIONS

Reduced junior doctor workload. (Paton, et al 2003)

More direct supervision of prescribing (e.g. Discussion and review of drug charts with consultant in ward rounds). (Paton, et al 2003)

and various defences have been proposed to avert these.

DEFENCES

Nurses being able to question doctors prescribing habits.

Increasing the number of clinical pharmacists in a hospital. (Misner, 2002)

Doctors improving their own defences by recognising circumstances in which they might make errors (e.g. dealing with non-psychotropic drugs or other teams patient) (Dean, 2002)

No prescription errors during our audit were reported at a local level. The National

Reporting and Learning System which forms part of the NPSA will allow NHS employees anywhere in England and Wales to report patient safety incidents or ‘near misses’ which they are involved in or witness. The information will be collected via a specific reporting form and stored anonymously. The NPSA’s role will be to analyse the data, identify national patterns and where risks are identified to produce solutions to prevent patient harm. This service is designed to complement rather than replace local reporting arrangements.

Potential limitations to this study are that it was unblended and uncontrolled. There was also no reliability testing of the identification of errors and no assessment of their clinical significance. It could be argued that errors involving failure to sign the prescription (representing the majority of errors identified) may be less significant than many other types of error. We did not gather information on how many (if any) of the errors were detected and remedied by the pharmacist.

CONCLUSION

Raising awareness of current prescribing practices in mental health trust employees within an educational forum may be useful in reducing gross numbers of prescribing errors. Given that trainee doctors move jobs regularly it may be appropriate to incorporate an educational intervention as part of a Trust’s induction programme. These meetings can be used to emphasise error-producing conditions, document current error rates and educate in a blame free environment. Further research is required to ascertain whether an educational forum can be viewed as an effective intervention in reducing prescription errors and subsequent harm to psychiatric in-patients.

ACKNOWLEDGEMENTS

We thank Dr Tim Gale from QEII Hospital, Welwyn Garden City, Hertfordshire Partnership NHS Foundation Trust and University of Hertfordshire for assistance with the statistical analysis.

REFERENCES

Dale, A, Copeland, R, Barton, R. (2003) Prescribing errors on medical wards and the impact of clinical pharmacists. International Journal of Pharmacy Practice. 11: 19–24.

Dean, B, Barber, N, Schachter, M. (2000) What is a prescribing error? Quality in Health Care. 9: 232–237.

Dean, B, Schachter, M, Vincen,t C, Barber, N. (2002a) Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 359: 1373–1378.

Dean, B, (2002b) Learning from prescribing errors. Quality and Safety in Health Care. 11(3):258-60.

Department of Health (2000) An Organisation with a Memory. Report of an expert group on learning from adverse events in the NHS. The Stationery Office, London.

Grasso, B C, Genest, R, Jordan, C W, Bates, D W. (2003a) Use of chart and record reviews to detect medication errors in a state psychiatric hospital. Psychiatric Services. 54: 677–681.

Grasso, B, Bates, D. (2003b) Medication Errors in Psychiatry: Are patients being harmed? Psychiatric Services. 54(5): 599.

Haw, C, Stubbs, J. (2003) Prescribing errors at a psychiatric hospital. Pharmacy in Practice. 10: 64–66.

Haw, C, Dickens, G, Stubbs, J. (2005) A review of medication administration errors reported in a large psychiatric hospital in the United Kingdom. Psychiatric Services. 56:1610–13.

Hawkey, C J, Hodgson, S, Norman, A, Daneshmend, T K, Garner, S T. (1990) Effect of reactive pharmacy intervention on quality of hospital prescribing. British Medical Journal. 300: 986–990.

Lesar, T, Briceland, L, Stein, D, (1997) Factors related to errors in medication prescribing. Journal of the American Medical Association. 277, 312-317.

Maidment, I D, Lelliott, P, Paton , C. (2006) Medication errors in mental healthcare: A Systematic Review. Quality and Safety in Health Care. 15; 409-413.

Misner, E. (2002) Consequence of drug dose and risk for medical error. http://bmj.com.cgi/eletters/324/7346/1113.

Paton, C, Gill-Banham, S. (2003) Prescribing errors in psychiatry. Psychiatric Bulletin. 27: 208–210

Reason J (1990) Human Error. New York: Cambridge University Press.

Stubbs, J, Haw, C, Cahill, C. (2004) Auditing prescribing errors in a psychiatric hospital. Are pharmacists’ interventions effective? Hospital Pharmacist. 11: 203–206.

Stubbs, J, Haw, C, Taylor, D. (2006) Prescription errors in psychiatry - a multi-centre study. Journal of Psychopharmacology. 20(4):553-61.

First Published Febrtuary 2008

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