The Pharmaceutical Journal
Vol 268 No 7183 p133-134
2 February 2002

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How pharmacists can help to reduce new junior doctors' prescribing errors

Many junior doctors will be starting new jobs this month potentially giving rise to an increased number of medication errors. Clare Bellingham looks at what pharmacists should be doing to prevent this

A strong suspicion exists that rates of medication errors increase in February and August: the times that junior doctors begin new jobs. However, there is a lack of data to prove this. Pharmacists tend to agree that they make more interventions in these months than at other times of the year, but again there are no hard data to demonstrate it. Mistakes tend to occur more frequently when people are inexperienced, so this picture of medication errors is not unreasonable.

The important issue is how to prevent errors from happening. Pharmacists are trained to spot prescribing errors and so prevent patients receiving the wrong medication. But is there more they can do? And how else can errors be prevented? The introduction of clinical governance means that health care professionals can no longer ignore the existence of prescribing errors but need to find ways to prevent them from happening.

The recent Audit Commission report, "A spoonful of sugar", highlighted an upward trend in the number of deaths in the UK attributed to medication errors. This was, perhaps not surprisingly, one of the most widely covered aspects of the report.

"A spoonful of sugar" recognised the problems faced by junior doctors: "Medication errors are more likely to happen when new doctors arrive to work in hospitals. Only a small proportion of doctors surveyed felt that their induction dealt adequately with medicines management issues," it says. The report identifies the important role that pharmacists can play. "Pharmacists need to be integrated into the clinical team. Pharmacists are experts in pharmacology and bringing them closer to the patient improves the quality of care and reduces costs. Pharmacists need to be used to anticipate medication errors."

Dr Norman Lannigan, chief pharmacist, Lothian University Hospitals NHS Trust, says: "Pharmacy's reason for being in hospitals is about the safe and effective use of medicine." Pharmacists should work with junior doctors, as part of a team, to ensure this, he says.

Minimising errors

In order to tackle the problem of errors, it is worth considering why they occur. Professor Tom Walley, professor of clinical pharmacology, Prescribing Research Group, University of Liverpool, says that medication errors arise because people:

• Have too many things to do at once
• Do not have appropriate resources
• Are aware of their ignorance but have no time to look things up

The Audit Commission report suggest that medication errors can be minimised by:

• Changing the risk management culture to encourage the reporting of errors and learning from them
• Providing formal induction of all new clinical staff and continuing training and competency assessments
• Redesigning processes and using computer technology so that prescribers have immediate access to information about both the medicine and the patient
• Developing clinical pharmacy services to maximise medicines' efficacy and minimising medicines' toxicity

Roles for pharmacists

So what roles can pharmacists play in preventing errors? Dr Lannigan says that pharmacists should be involved in:

• Education of staff
• Working as part of the team to influence the quality of prescribing
• Policy writing to set up systems to ensure safe use of medicines
• Monitoring and auditing of prescribing

Professor Walley identifies ward pharmacists as having an important role in error prevention. "Ward pharmacists are key. They provide the continuity that junior doctors need and are a resource of information." He adds: "We need more ward pharmacists. The role of the ward pharmacist should not be seen as a service role but rather as an educational role for both doctors and nurses.

"There is also a question of professional relationships," he says. "Junior doctors should see the pharmacists as someone to learn from but this is often not the case at the moment." He suggests that if doctors are trained to take a multidisciplinary approach and pharmacists develop good interpersonal skills then this would enhance better working relationships.

"It would be ideal if it happened at an undergraduate level but schools of pharmacy and medicine are often not located close together. Therefore, a better time might be at the induction of house officers." (See below.)

Professor Walley believes that training and ongoing support are essential to prevent junior doctors making prescribing errors. Support mechanisms he suggests include use of information technology, ward pharmacists, ongoing education and personal reviews of prescribing.

"A spoonful of sugar" states: "Enabling pharmacists to contribute more fully to patient care reduces patient morbidity and saves money. In particular, the presence of a pharmacist on ward rounds as a full member of the patient care team reduces prescribing errors significantly."

It adds: "Clinical pharmacy activities should also be extended to pharmacist prescribing and to taking patients' medication histories. There is evidence that pharmacists are five times more accurate than doctors in writing discharge prescriptions."

Extended hours support

Dr Lannigan says that demand for the hospital's on-call pharmacist service doubles twice a year: in February and August. "This is evidence for providing an extended service," he says.

Keith Farrar, chief pharmacist, Wirral Hospital, and chairman of the Royal Pharmaceutical Society's Hospital Pharmacists Group, says: "Pharmacists need to provide clinical support at the bedside at the time when doctors are actually doing the prescribing." Most hospital pharmacies are open on Monday to Friday from 9am until 5pm. However, the majority of prescribing errors occur when the pharmacy is shut. "I would suggest that junior doctors need pharmacist support outside normal pharmacy opening hours; perhaps even more so because senior medical colleagues are around during the day to give advice but not at night.

"If we aspire to be a clinical profession providing pharmaceutical care then we have to accept that pharmacy is a 24-hour-a-day, seven-day-a-week job based at ward level. It cannot be delivered on a one-person basis outside normal opening hours."

This type of change will only happen on a gradual basis. Mr Farrar suggests identifying areas of greatest risk, for example, admission into hospital, and the times of greatest risk. The incremental steps can be made with the aim of providing an adequate clinical pharmacy service at those times, he advises.

Mr Farrar explains the way in which the pharmacy department operates at Wirral involves a pharmacist being attached to a consultant team and an identifiable group of patients, not to a ward. "We try to see medical patients, where the majority of prescribing takes place, as soon as possible after admission," he says. The pharmacy provides a service, staffed by pharmacists and technicians, to medical admission from 8.30am to 9pm on Mondays to Fridays, 9am to 5pm on Saturdays and for four hours during the day on Sundays.

"The pharmacist is responsible for monitoring changes to the patient's medication through their stay and ensuring that they are taking appropriate drugs. They might also be involved in writing or checking discharge prescriptions."

Pharmacists participate in ward rounds. "Consultants trust pharmacists' opinions and junior doctors see this and trust them too. It is a team approach: doctors are happy for the pharmacists to intervene and make changes to therapy."

Supervision

In order to tackle the specific problems of prescribing errors among junior doctors, the hospital has suggested that junior doctors do not prescribe for the first six weeks in the job, except when closely supervised. Mr Farrar explains that the general feeling among staff at the hospital was that this is a common sense approach. However, it has not been audited yet and it is not known whether, despite supporting the sentiment, it works in a practical setting (see "Broad Spectrum", p136).

Protocols for junior doctors

Not allowing junior doctors to prescribe would certainly reduce the risk of errors.

Dr Lannigan points out that in the case of intrathecal injections this is exactly what has happened.

In order to reduce the possibility of medication incidents occurring, Lothian University hospital has protocols in place which prevent junior members of staff from prescribing certain drugs. Dr Lannigan says that, for example, the hospital has a protocol in place for chemotherapy drugs which prevents prescribers from deviating from a specific list of drugs unless they are at a certain level of seniority.

This type of approach can be supplemented by the use of information technology. The Wirral Hospital is at the forefront of introducing IT solutions. "Electronic prescribing certainly reduces prescribing errors. It resolves the problem of not being able to read either the doctor's handwriting or signature," Mr Farrar says. It also helps doctors identify what items are included in the hospital's formulary. "We have customised the layout of the screens so it guides the prescriber and reduces risk." For example, if a doctor wants to prescribe low molecular weight heparin for deep vein thrombosis, they first click on heparin, then DVT treatment, then enter the patient's weight and the computer takes them to the appropriate dose, he explains.

Pharmacist prescribing

"Pharmacists should take responsibility for making sure that the needs of the patient in terms of their medicines are properly assessed and for ensuring that they get the medicines required and none that they shouldn't," said Mr Farrar. "Who actually writes the prescription is academic. If you make all the decisions in terms of treatment and someone else writes the prescription, the pharmacist is still responsible for his or her actions."

"Pharmacists are not good at diagnosis. A team approach is needed. The doctor examines the patient and decides what is wrong. The pharmacist then decides the treatment. It is immaterial who actually signs the prescription: an informed, group decision is what is important."

Dr Lannigan adds that many consultants think that pharmacists are competent to prescribe. "If pharmacists become supplementary prescribers then it would reduce the need for junior doctors to get involved in prescribing," he says.

Changing attitudes

Perhaps the most important message is that, in order to tackle errors, a move away from the blame culture is needed. Dr Lannigan says that people should concentrate on finding the root cause of errors and not on assigning blame. He adds that errors should be termed "incidents" because "errors" suggest blame.

"A spoonful of sugar" is a hugely important document for pharmacy that recognises the role that clinical pharmacists can play in reducing errors. Ensuring that a pharmacist is part of multidisciplinary teams managing patients' care in hospitals is the first step forward.