The Pharmaceutical Journal
Vol 268 No 7183 p136
2 February 2002

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Time to review prescribing in hospitals by preregistration house officers

By Keith Farrar

The media response to the Audit Commission report "A spoonful of sugar — medicines management in NHS hospitals"¹ was to focus on the 500 per cent increase in reports of medication-related deaths over the past 10 years. Although not all these deaths have not been due to errors (the system used to classify them also includes other causes) there is certainly growing concern about the risks associated with medication errors.

This rising incidence of cases is coupled with a fall in public acceptance of errors in health care. In an analysis of medication errors that have led to manslaughter charges, Ferner identified 17 case reports, 53 per cent of which involved junior doctors. If only the hospital-related cases are considered the incidence of junior doctor-related cases increases to 69 per cent.²

Estimates of prescribing errors are difficult to make but a series of studies in the United States and Australia has estimated that the medication error rate is between 5 and 17 per cent. The rate of drug-related error or adverse drug event (ADE) varies depending on the method chosen to identify the rate of error. Classen et al³ identified a rate of ADEs of 1.7 per cent based on a review of computer records. Bates et al⁴ found a 7.3 per cent rate of serious medication error by observational studies.

Medication errors are not always trivial. In their analysis, Bates and colleagues found that 1 per cent were fatal in outcome, 12 per cent were life-threatening and 30 per cent were serious, with 42 per cent of the life-threatening or serious errors found to be preventable. These preventable ADEs occurred most frequently during prescribing (56 per cent) or administration (34 per cent). An Australian study found that preventable errors led to significant patient morbidity and mortality, with cognitive errors, such as making the wrong diagnosis or choosing the wrong drug more likely to result in permanent disability.⁵

Prescribing is a 24-hour-a-day, seven- day-a-week activity,⁶ with doctors in training responsible for most of it, and this can represent an appreciable risk to patients.⁷ The risk is often greater when the doctor in training is working outside of "office hours" with minimal support from peers or other clinical support staff.^8,9 The process of failure mode and effects analysis,¹⁰ borrowed from the aviation industry, has been used to highlight risks in the use of medicines. One of the biggest areas of risk is associated with lack of detailed knowledge about the medicines being prescribed or administered.

Anecdotal reports suggest that interventions by pharmacists increase during August and February as junior doctors either join the hospital or change discipline and are required to take on the burden of prescribing. The, perhaps subjective, feeling of many pharmacy and nursing staff is that the majority of doctors in training learn about therapeutics and prescribing by doing it. Although the suggestion (in a BBC drama, "Cardiac arrest", in 1994) that junior doctors "kill patients while learning" was robustly refuted by Aylin in the British Medical Journal¹¹ an earlier comment by Dillner saw this a frightening realism.¹²

The recent changes in the NHS that have highlighted clinical quality through the clinical governance¹³ process may have helped to increase the rate of reporting of clinical error. The change to make chief executives accountable for clinical quality as well as financial performance is certainly one which means that the risk management aspects of medicines management are now at least as important as the financial aspects.

The Crown review of prescribing, supply and administration of medicines¹⁴ raised the issue of competence to prescribe stating: "All legally authorised prescribers ... should never prescribe in situations beyond their professional competence." It also recommended that "postgraduate deans should agree a safe framework within which preregistration house officers could prescribe medicines ... subject to close monitoring by their clinical supervisor".

The changes in junior doctor training have raised questions about whether pre-registration house officers have the knowledge and skills to prescribe effectively on appointment. Clinical governance requires us to ensure that patient safety is optimised. In the light of these changes, is it time for us to review the issue of prescribing by preregistration house officers in hospitals? The suggestion that preregistration house officers are not asked to prescribe, except under close supervision, for the first six weeks has recently been accepted in my own hospital. The impact of this initiative has yet to be audited.

Keith Farrar is chief pharmacist at Wirral Hospital. He is currently chairman of the Royal Pharmaceutical Society's Hospital Pharmacists Group