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Reducing Prescribing Errors In The Communities

Table of Contents

Introduction. 3

Background. 4

Measurement 6

Design. 9

References. 11

Introduction

Prescribing error is regarded as the most common type of medicinal error for primary as well as secondary care. It falls under medication errors. In the United States alone it accounts for killing over 7000 patients in a year (Franklin and Puaar, 2020). Medication errors consist of inaccuracies and mistakes at the time of selection and ordering of treatments like illegible prescriptions and wrong doses.  It is also responsible for near about 1 in 20 admissions in hospitals. The incidence in the United Kingdom can be found similar to that of the United States. Among all kinds of medication errors, prescribing error is found to be the most serious and fatal. When a error is made, if not identified properly, it is applied systematically and can cause considerable harm (Mantri et al., 2019). In the hospitals of the United Kingdom, prescribers are found to make mistakes in almost 1.5% of the prescriptions. In addition, errors related to primary care happen in more than 11% of the prescriptions. Prescribing errors in communication between the two industries is also found to be below the ideal level (Pontefract et al., 2018). In one research, it has been found that about half of the patients could not take proper medicine in one month post discharge. Non-adherence, also regarded as the result of poor prescribing, is known for affecting nearly 30 to 50% of patients who take medications for specific chronic conditions. 

The importance of errors in prescribing can be magnified by the steep prescribing frequency. It is considered as a very common type of treatment for the United Kingdom National Health Service and the community where in the year 2000; more than 637,000,000 prescriptions were found which cost 12.3% of total expense of the NHS (Alqenae, Steinke and Keers, 2020). In spite of the prescribing process being a comparatively negative skill, there is absence of a single and simple solution for getting rid of the problem. There is a requirement of a wide range of measures for making a breakthrough (Soler and Barreto, 2019). 

In light of the evidence, the rationale behind developing a report on reduction of prescribing errors in the communities is to identify the facilitators and barriers of prescription errors reporting at primary care. With the help of this research, it will be possible for understanding the influence of contextual as well as socio-cultural influence, important feedback systems, learning processes and useful socio technical aspects of the application of useful error reporting technologies.

Background

Prescribing errors are known for causing unintentional, unavoidable and severe problems for all the patients with an economic burden to the system of healthcare estimated to be $42 billion every year. In England, a modeling research was conducted which revealed that more than 237 million errors related to medication happen every year (Sabir et al., 2019). These can occur at any area of usage of medication, form dispensing or prescribing to monitoring or administration. While errors of administration are responsible for about 55% of errors, 91% of them are regarded as having very little or no ability to cause harm to the patients. Prescribing errors are known for causing 21.3% of all kinds of errors. However, they also cause 33.9% of errors which are clinically significant. 71% of them happen in any primary care unit. Primary care is sometimes found to be providing the first point of contact in any system of healthcare and consists of community pharmacy and general practice (Alsaidan et al., 2018). Almost all the prescriptions for the UK National Health Service are developed in any primary care with 80 million above primary care prescription items are processed every month in England. It has been found that more than 5% of these contain unsafe or substandard prescribing. However, the figure can vary. In the case of settings of secondary care, every process is connected with usage of medication that are generally found in any single enterprise like a hospital trust. However, within the boundary of primary care, all the stages are found to go beyond the care providers’ boundaries and the medications are generally self-administered with very few or almost no interactions with the professionals of healthcare (Tully et al., 2019). This is known for making the learning and tracking process of prescribing errors extremely difficult. A prescribing error can be considered as a writing process or prescribing decision that is responsible for considerable decrease in the probability of on time and effective treatment or rise in the harm risks at the time of making comparisons with the practices that are generally accepted (Nguyen, Mosel and Grzeskowiak, 2018). Some research has been conducted till date for identifying the prescribing eros present in case of primary care. This has detected trends like increase in the prescribing error prevalence for the elderly people, children and the patients suffering from polypharmacy. Moreover, an increase in errors have also been detected at the time of giving medicines that have high risks or on occasions when someone is being prescribed for the first time.

Community pharmacists in case of primary care have the position of identifying all sorts of prescribing errors and intervening prior to dispensation of medications for the patients. On the other hand, community pharmacists and general practices are regarded as independent contractors. Their share of knowledge in the care is not unlimited. Researchers making an attempt to quantify the prescription interventions for pharmacists have stated that around 1 to 2% of different prescriptions need a pharmacist for contacting a prescriber for corrections and clarifications (Wheeler et al., 2018). On the contrary, community pharmacists are also known for not reporting incidents related to patient safety, namely prescribing errors. In the year 2001, the National Patient Safety Agency was established for the mobilization of the movement for patient safety in the NHS. It is recommended to significant event analysis by the teams of primary care. This entitles effective audit of any effective patient safety event for ascertaining the things that can be learnt from the incident for improving the care given to the patients. It also emphasizes on recording the incidents related to patient safety and launching the national reprigin and learning process. This has developed the culture and frequency of reporting of incidents every year. It also comprises a 12.3% rise in the total number of incidents reported in between January and March in the year 2020 while comparing with the same time in the previous year (Alfadl, Alrasheedy and Alhassun, 2018). The Nationals reporting and learning systems are known for enabling incident reports for patient safety that need to be included to a central database. After that all those reports can be evaluated for the identification and sharing of important contributory factors and patterns which are useful for preventing medication related harms in the future. It is possible to do the reporting process in bulk individually or with the help of local systems of risk management. It is directed to the website of the National reporting and learning system with the help of eFrom (Korb-Savoldelli et al., 2018). At present, only large organizations from secondary care have bought local risk management systems. This means that the primary care reporting figures have stayed low. In the year 2012, the National Patient Safety Agency became an integral element of NHS who are continuing NRLS functions (Gajdács, Paulik and Szabó, 2020). A project on improvement of patient safety incident management system is currently underway which is going to ultimately make a replacement of NRLS. This is going to be developed for working properly through the NHS for simplifying the process of reporting errors for all organizations (Hockly, Williams and Allen, 2018). 

A proactive approach to reporting errors can help in identifying important trends and preventing the incident occurrences that can cause substantial harm to the patients. In case of primary care settings, underreporting of errors related to prescribing is very well known. Additionally, the care organization and the prescription movement from general to community pharmacy is responsible for creating hardships for professionals in making important decisions regarding reporting at the time of identification of any error. 

Measurement

Application of useful methodologies is regarded as an effective process of following any structure that helps in supporting the development of work. The process of thinking how to develop is the important plan that teams need to map out for developing the most suitable strategy. Therefore selections of important tools are important for any team and individuals in considering the msot useful aspects of testing and making changes (Zeleznikar et al., 2019). For developing an effective understanding of the prescribing errors, valid and reliable data have to be gathered, evaluated for establishing priorities regarding usage of most important sources for identifying the present problem. 

All the sources were collected and analyzed meticulously. Data related to prescribing errors in the primary care communities have been obtained from quality reports, notes of patients and evaluation of the latest educational sessions conducted for staff on prescribing errors and the compliance required. Moreover, there are other factors which can affect the multiple works for professionals and decrease the prescribing errors (Hussain, Reynolds and Zheng, 2019). These sources have not been found to be that much informative. For this reason, other sources were identified and used. These include important multi professional meetings for work groups to provide insight to all the possible issues, audits for measuring compliance with the documentation of the plan for reducing prescribing errors and evaluation of the events related to prescribing errors for implementing and documenting prescribing errors properly. 

With the help of the garnered information, root cause analysis has been done and the main causes of prescribing errors in specific areas of case were analyzed. 

Individual

Individual education is what is required for decreasing errors related to prescribing this can bed of many forms, for instance academic detailing where a professional pays a visit to any workplace for anyone to one session that involves education. A Cochrane review evaluated a face to face outreach visit with the help of a trained person from a health professional. Total 18 randomized trials were done. 13 of them were found to target the prescribing process (Manias, 2018). All kinds of outreach programs consist of important components like conferences or written materials. In addition, there are audit or reminders. Often, a feedback process was applied. From all research, improved behaviors have been identified. However, there are some studies that examine costs or outcomes of patients. 

Environment and facilities

Some researchers have highlighted the benefits of making pharmacists check and review the order of medication properly. For example, pharmacists at any US hospital applied an electronic process for reviewing specific prescriptions. This was responsible for alerting the prescriber and pharmacist to analyze the errors related to doses and specific allergies (Lapointe-Shaw et al., 2020). As a result, the prescription errors decreased significantly. In another US hospital, an examination on some pediatric clinical pharmacists was done. There errors of prescription were intercepted. Over 8% of possibly detrimental prescribing errors were found by the pharmacists. Another example is from England (Sakeena, Bennett and McLachlan, 2018). There in a hospital, the effect of pharmacists for the prevention of prescribing errors upon discharge was investigated. It was found that  data collected routines displayed intervention of 8% of specific orders of medications by any pharmacist.total 83% of errors in orders without any reference to doctors were intercepted (Scott et al., 2018). Selection of drugs, errors in dosage and omission were found as the problems occurred frequently. 

People

Pharmacists can play an important role in decreasing errors of prescribing in different primary care units. However, it is worth noting that almost all the research done in this area is very small, observational and descriptive (Aboneh et al., 2020). It is known for describing interventions taken in particular sites. There is very little long term information available regarding the outcome. For instance, in a study based in the US, the role of any pharmacist in developing safety of medication in primary care with the help of focus groups has been evaluated. It was found that patients tended to consult with more than one doctor, however, they were likely to see only one pharmacist. However, they were wont to report more of the prescribing errors to the pharmacist than to their doctors. Pharmacists played the role of final interceptors. They helped in identifying prescription errors before they could get to the patients (Zawahir, Lekamwasam and Aslani, 2019). It is possible for pharmacists to contact doctors who provide primary care for clarifying prescriptions or suggesting important changes. In the case of the US, Pharmacy call backs to a total twenty two primary cares were recorded over a period of two weeks. Moreover, maintaining number records and specific types of pharmacy related queries aided the practices in developing important interventions for reducing errors (Mueller et al., 2019). Few proactive approaches for pharmacist reviews have also been evaluated. For instance, in Switzerland, some quality circles were formed where the community pharmacists were responsible for reviewing the prescription of twenty four GPs. Some of the useful elements added to specific prescription review, education and constant process of quality education and improvement, feedback and local networking of useful data regarding choices of drugs and costs were also taken into account. Evaluation of nine years’ value of data was found to improve safety and quality for prescribing and 42% reduction of the costs for drugs in comparison with a control group. This presents US$225,000 every year (Chang et al., 2019). 

Methods

A systematic research was conducted on KB and NH for the identification of researches which are relevant to important research objectives. All the researched data sets consisted of Chochrane, PubMed and web of science (Earl et al., 2018). The strategy of research was improved. Testing was done along with the team for review and was dependent on predefined eligibility criteria. The keywords for the eligibility criteria were detected and adjustment was made appropriate for every database. Full explanation of the specific terms of research has been found. Google scholar was used for searching the gray literature. In addition, essential websites from national healthcare and primary care organizations based in the UK were searched. Reference lists of all the researches included were researched manually for all the papers which were relevant. 

From the above root cause analysis method, it has been found that despite the appreciation of the healthcare professionals of the reporting of prescription errors, there are many barriers to implementing them properly. No proper prescription error definition was found and it is very difficult to understand the things that need to be reported (Atif et al., 2020). Moreover, there is a difference between community pharmacies and general practices which can further make collaborative working barriers and shared learning processes. Further investigation is required for discovering the process using which it becomes possible for optimizing the process of prescribing error reporting for providing support to learning and developing patient safety. 

Design

Factors of human approaches are connected with the interface between systems and tools and the employees account for them (Oqab, Pournazari and Sheldon, 2018). Most of the studies regarding redesigning of tasks and equipment are for decreasing errors related to prescribing that have specific focus on the systems of electronic prescribing and computerized systems for providing support on making decisions. These studies are responsible for describing the realization process of important systems and their results. However, they not only examine the workflow interlinks, human factors and interruptions are also evaluated. 

At the time of interpretation of the findings in the section, it is necessary to understand that there are many differences in terms of prescribing and the responsibilities of pharmacists from different countries. For instance, electronic systems have been developed for decreasing ht errors related to transcription, however, it is possible for applying transcription errors the same way both in UK and US. In the case of the UK, prescription is written directly onto the drug chart by the doctors (Alsaidan et al., 2018). Researches that pay attention to decreasing errors of transcription have very little relevance.

E-prescribing is the design that is very well known and generally uses the terms like computerized physician order entry (CPOE) or computerized pharmacist order entry where the handwritten orders of pharmacists. These are useful for transcribing the handwritten orders of prescribers into a system. This is regarded as an electronic process for using important instructions related to treatment for patients. Medication, equipment and other kinds of orders for treatment are generally sent using a computer network to several departments and staffs like radiology, pharmacy and laboratory which can be useful for managing the orders. Prior to the availability of e-prescribing systems, doctors conventionally wrote or verbally stated patient care instructions. Ancillary staff and nurses then transcribed all that information prior to being auctioned. It was usually thought that these types of notes can cause many errors and delays. For this reason, it is recommended by the US institute of medicine for implanting as standard (Wheeler et al., 2018). 

There are decision support tools which account for providing prompts that provide aid to prescribers for getting rid of errors at the time of entering or making prescriptions. These alert systems and support tools are considered s standalone systems. Here, important alert systems are used for specific prescribing tools. However, all the implications are analyzed alternatively. There is evidence on the benefits of decision support tools like prescriber prompts and alerts. A survey on computerized drug prompts and alerts have identified that 23 from 27 researches suggest development of prescribing behavior or decreasing of the level of error (Alsaidan et al., 2018). The variation of the effet is dependent on the specific types of decision. Five out of 27 researches report important beentis for health as well as clinical service results. Another survey found that four out of seven research regarding standalone clinical support processes were responsible for making improvements in terms of prescribing errors. Three of them could not. Almost all the research was not developed for detecting the differences in case of adverse events of drug. Moreover, small home grown systems were evaluated instead of commercial processes.  

Decision support tools consist of important clinical guidelines and information. In France, research has been done for testing whether development of guidelines regarding antibiotics can become accessible to doctors resulting in rise in the guidelines adherence. Very little adherence in this case can be considered as prescribing error. Hospitals can be changed from having all the available guidelines in the form of booklets on wards for embedding the guidelines into the system of e-prescribing.

References

Franklin, B.D. and Puaar, S., 2020. What is the impact of introducing inpatient electronic prescribing on prescribing errors? A naturalistic stepped wedge study in an English teaching hospital. Health informatics journal, 26(4), pp.3152-3162.

Mantri, S., Fullard, M., Gray, S.L., Weintraub, D., Hubbard, R.A., Hennessy, S. and Willis, A.W., 2019. Patterns of dementia treatment and frank prescribing errors in older adults with Parkinson disease. JAMA neurology, 76(1), pp.41-49.

Pontefract, S.K., Hodson, J., Slee, A., Shah, S., Girling, A.J., Williams, R., Sheikh, A. and Coleman, J.J., 2018. Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre-post study. BMJ quality & safety, 27(9), pp.725-736.

Alqenae, F.A., Steinke, D. and Keers, R.N., 2020. Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. Drug safety, 43(6), pp.517-537.

Soler, O. and Barreto, J.O.M., 2019. Community-level pharmaceutical interventions to reduce the risks of polypharmacy in the elderly: overview of systematic reviews and economic evaluations. Frontiers in pharmacology, 10, p.302.

Sabir, F.R., Tomlinson, J., Strickland-Hodge, B. and Smith, H., 2019. Evaluating the Connect with Pharmacy web-based intervention to reduce hospital readmission for older people. International journal of clinical pharmacy, 41(5), pp.1239-1246.

Alsaidan, J., Portlock, J., Aljadhey, H.S., Shebl, N.A. and Franklin, B.D., 2018. Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries. Saudi Pharmaceutical Journal, 26(7), pp.977-1011.

Tully, A.P., Hammond, D.A., Li, C., Jarrell, A.S. and Kruer, R.M., 2019. Evaluation of medication errors at the transition of care from an ICU to non-ICU location. Critical care medicine, 47(4), pp.543-549.

Nguyen, M.N.R., Mosel, C. and Grzeskowiak, L.E., 2018. Interventions to reduce medication errors in neonatal care: a systematic review. Therapeutic advances in drug safety, 9(2), pp.123-155.

Wheeler, A.J., Scahill, S., Hopcroft, D. and Stapleton, H., 2018. Reducing medication errors at transitions of care is everyone’s business. Australian prescriber, 41(3), p.73.

Alfadl, A.A., Alrasheedy, A.A. and Alhassun, M.S., 2018. Evaluation of medication counseling practice at community pharmacies in Qassim region, Saudi Arabia. Saudi Pharmaceutical Journal, 26(2), pp.258-262.

Korb-Savoldelli, V., Boussadi, A., Durieux, P. and Sabatier, B., 2018. Prevalence of computerized physician order entry systems–related medication prescription errors: a systematic review. International journal of medical informatics, 111, pp.112-122.

Gajdács, M., Paulik, E. and Szabó, A., 2020. Knowledge, attitude and practice of community pharmacists regarding antibiotic use and infectious diseases: a cross-sectional survey in Hungary (KAPPhA-HU). Antibiotics, 9(2), p.41.

Hockly, M., Williams, S. and Allen, M., 2018. Transfer of care–a randomised control trial investigating the effect of sending the details of patients’ discharge medication to their community pharmacist on discharge from hospital. International Journal of Pharmacy Practice, 26(2), pp.174-182.

Zeleznikar, E.A., Kroehl, M.E., Perica, K.M., Thompson, A.M. and Trinkley, K.E., 2019. Integration of community pharmacists in transition of care (TOC) services: current trends and pharmacist perceptions. Journal of pharmacy practice, 32(1), pp.28-35.

Hussain, M.I., Reynolds, T.L. and Zheng, K., 2019. Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review. Journal of the American Medical Informatics Association, 26(10), pp.1141-1149.

Manias, E., 2018. Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert opinion on drug safety, 17(3), pp.259-275.

Lapointe-Shaw, L., Bell, C.M., Austin, P.C., Abrahamyan, L., Ivers, N.M., Li, P., Pechlivanoglou, P., Redelmeier, D.A. and Dolovich, L., 2020. Community pharmacy medication review, death and re-admission after hospital discharge: a propensity score-matched cohort study. BMJ quality & safety, 29(1), pp.41-51.

Sakeena, M.H.F., Bennett, A.A. and McLachlan, A.J., 2018. Enhancing pharmacists’ role in developing countries to overcome the challenge of antimicrobial resistance: a narrative review. Antimicrobial Resistance & Infection Control, 7(1), pp.1-11.

Scott, I.A., Pillans, P.I., Barras, M. and Morris, C., 2018. Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review. Therapeutic advances in drug safety, 9(9), pp.559-573.

Aboneh, E.A., Stone, J.A., Lester, C.A. and Chui, M.A., 2020. Evaluation of patient safety culture in community pharmacies. Journal of patient safety, 16(1), p.e18.

Zawahir, S., Lekamwasam, S. and Aslani, P., 2019. A cross-sectional national survey of community pharmacy staff: Knowledge and antibiotic provision. PloS one, 14(4), p.e0215484.

Mueller, B.U., Neuspiel, D.R., Fisher, E.R.S., Franklin, W., Adirim, T., Bundy, D.G., Ferguson, L.E., Gleeson, S.P., Leu, M., Quinonez, R.A. and Rinke, M.L., 2019. Principles of pediatric patient safety: reducing harm due to medical care. Pediatrics, 143(2).

Chang, J., Xu, S., Zhu, S., Li, Z., Yu, J., Zhang, Y., Zu, J., Fang, Y. and Ross-Degnan, D., 2019. Assessment of non-prescription antibiotic dispensing at community pharmacies in China with simulated clients: a mixed cross-sectional and longitudinal study. The Lancet Infectious Diseases, 19(12), pp.1345-1354.

Earl, J.P., Adappa, N.D., Krol, J., Bhat, A.S., Balashov, S., Ehrlich, R.L., Palmer, J.N., Workman, A.D., Blasetti, M., Sen, B. and Hammond, J., 2018. Species-level bacterial community profiling of the healthy sinonasal microbiome using Pacific Biosciences sequencing of full-length 16S rRNA genes. Microbiome, 6(1), pp.1-26.

Atif, M., Asghar, S., Mushtaq, I. and Malik, I., 2020. Community pharmacists as antibiotic stewards: A qualitative study exploring the current status of Antibiotic Stewardship Program in Bahawalpur, Pakistan. Journal of infection and public health, 13(1), pp.118-124.

Oqab, Z., Pournazari, P. and Sheldon, R.S., 2018. What is the impact of frailty on prescription of anticoagulation in elderly patients with atrial fibrillation? A systematic review and meta-analysis. Journal of atrial fibrillation, 10(6).

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