Prescribing error at hospital discharge: a retrospective review of medication information in an Irish hospital.

BACKGROUND: Prescribing error may result in adverse clinical outcomes leading to increased patient morbidity, mortality and increased economic burden. Many errors occur during transitional care as patients move between different stages and settings of care. AIM: To conduct a review of medication information and identify prescribing error among an adult population in an urban hospital. METHODS: Retrospective review of medication information was conducted. Part 1: an audit of discharge prescriptions which assessed: legibility, compliance with legal requirements, therapeutic errors (strength, dose and frequency) and drug interactions. Part 2: A review of all sources of medication information (namely pre-admission medication list, drug Kardex, discharge prescription, discharge letter) for 15 inpatients to identify unintentional prescription discrepancies, defined as: "undocumented and/or unjustified medication alteration" throughout the hospital stay. RESULTS: Part 1: of the 5910 prescribed items; 53 (0.9%) were deemed illegible. Of the controlled drug prescriptions 11.1% (n = 167) met all the legal requirements. Therapeutic errors occurred in 41% of prescriptions (n = 479) More than 1 in 5 patients (21.9%) received a prescription containing a drug interaction. Part 2: 175 discrepancies were identified across all sources of medication information; of which 78 were deemed unintentional. Of these: 10.2% (n = 8) occurred at the point of admission, whereby 76.9% (n = 60) occurred at the point of discharge. CONCLUSIONS: The study identified the time of discharge as a point at which prescribing errors are likely to occur. This has implications for patient safety and provider work load in both primary and secondary care.

Prescribing new drugs: qualitative study of influences on consultants and general practitioners.

OBJECTIVE: To explore consultants' and general practitioners' perceptions of the factors that influence their decisions to introduce new drugs into their clinical practice. DESIGN: Qualitative study using semistructured interviews. Monitoring of hospital and general practice prescribing data for eight new drugs. SETTING: Teaching hospital and nearby general hospital plus general practices in Birmingham. PARTICIPANTS: 38 consultants and 56 general practitioners who regularly referred to the teaching hospital. MAIN OUTCOME MEASURES: Reasons for prescribing a new drug; sources of information used for new drugs; extent of contact between consultants and general practitioners; and amount of study drugs used in hospitals and by general practitioners. RESULTS: Consultants usually prescribed new drugs only in their specialty, used few new drugs, and used scientific evidence to inform their decisions. General practitioners generally prescribed more new drugs and for a wider range of conditions, but their approach varied considerably both between general practitioners and between drugs for the same general practitioner. Drug company representatives were an important source of information for general practitioners. Prescribing data were consistent with statements made by respondents. CONCLUSIONS: The factors influencing the introduction of new drugs, particularly in primary care, are more multiple and complex than suggested by early theories of drug innovation. Early experience of using a new drug seems to strongly influence future use.

Proton pump inhibitors: a study of GPs' prescribing.

BACKGROUND: There has been a rapid increase in proton pump inhibitor (PPI) prescribing in recent years, and controlling the cost and improving the quality of prescribing is an issue of concern to many GPS: OBJECTIVE: Our aim was to compare GPs' usage of different PPIs and explore how GPs' PPI prescribing changes following the introduction of a cheaper competitor. METHODS: PPI prescribing data (PACT) for 53 GPs, who were selected as regular users of a teaching hospital, were monitored from January 1995 to December 1997. The GPs were located in two adjoining health districts and had been interviewed about influences on their decisions to begin prescribing lansoprazole. The PPI prescribing data were collected for the teaching hospital and the general hospital in the adjoining district. RESULTS: Complete prescribing data were available for 50 GPS: Total PPI prescribing increased throughout the study due mainly to increasing use of the new PPIS: Use of the new PPIs increased from 6 to 24% over 3 years. The proportion of maintenance doses prescribed increased from 3 to 12%. There was a 23-fold difference in total PPI prescribing and an 87-fold difference in lansoprazole prescribing between the highest and lowest prescribers. The uptake of pantoprazole was slower than that of lansoprazole. A rapid increase in the use of lansoprazole by the GPs followed an increase in use in the teaching hospital. CONCLUSION: Hospital prescribing was an important influence on the choice of PPI used by GPS: The wide variation in PPI prescribing suggests that there is scope for improvement in the quality and cost of PPI prescribing.

GPs' perceptions of patient influence on prescribing.

BACKGROUND: Controlling prescribing costs is an issue of concern to many GPs. OBJECTIVE AND METHODS: This paper is based on interviews with 21 GPs in which they were asked about influences on prescribing budgets. RESULTS: The results presented relate specifically to GPs' perceptions of the influence of patients on prescribing. Perceptions of patient demand were described both in terms of a general demand and demand by patients with specific health beliefs or particular social characteristics. Generally, GPs reported that decisions to prescribe were informed by a concern to maintain a good relationship with their patients, and not to risk the relationship by not prescribing when they believed a prescription was expected. CONCLUSIONS: Although information was available about whether practices had a 'high' or 'low' budget, and whether they were under- or overspent, there did not appear to be any relationship between GPs' beliefs that patient expectations affected their prescribing and whether they were under or over budget. This paper suggests that patient demand for prescriptions may not only be overestimated but also perpetuated by GPs' belief in its existence and a wish to maintain a good doctor-patient relationship.

Patient attitudes to over-the-counter drugs and possible professional responses to self-medication.

BACKGROUND: There is a paucity of research about patients' attitudes towards their doctor's recommending over-the-counter (OTC) remedies or about how patients respond to the doctor's suggestion to try an OTC remedy. OBJECTIVES: The aim of this study was to ascertain the attitudes of patients to OTC drugs. METHODS: 505 consecutive patients from each of six participating practices filled in a questionnaire. RESULTS: A total of 2765 (91.3%) patients responded. The responses from 2624 patients were from adults and are presented here. Based on the number of valid responses to each question, 53.8% of these patients were exempt from prescription charges, 55.1% took regular prescribed medication and 24.6% stated that they used OTC remedies regularly. There were generally positive attitudes to doctors enquiring about prior OTC use as well as to doctors making OTC recommendations in the consultation. However, patients expressed fairly negative attitudes towards pharmacists making generic substitutions and were even more hostile to the idea that pharmacists should make therapeutic substitutions. CONCLUSION: In conclusion, GPs should consider asking their patients regularly about their use of OTC medicines and also consider recommending OTC use if this is cheaper than FP10s. However, the public at present do not appear to be prepared for interventions by the pharmacist.

Evaluation of computerized decision support for oral anticoagulation management based in primary care.

BACKGROUND: Increasing indications for oral anticoagulation has led to pressure on general practices to undertake therapeutic monitoring. Computerized decision support (DSS) has been shown to be effective in hospitals for improving clinical management. Its usefulness in primary care has previously not been investigated. AIM: To test the effectiveness of using DSS for oral anticoagulation monitoring in primary care by measuring the proportions of patients adequately controlled, defined as within the appropriate therapeutic range of International Normalised Ratio (INR). METHOD: All patients receiving warfarin from two Birmingham inner city general practices were invited to attend a practice-based anticoagulation clinic. In practice A all patients were managed using DSS. In practice B patients were randomized to receive dosing advice either through DSS or through the local hospital laboratory. Clinical outcomes, adverse events and patient acceptability were recorded. RESULTS: Forty-nine patients were seen in total. There were significant improvements in INR control from 23% to 86% (P > 0.001) in the practice where all patients received dosing through DSS. In the practice where patients were randomized to either DSS or hospital dosing, logistic regression showed a significant trend for improvement in intervention patients which was not apparent in the hospital-dosed patients (P < 0.001). Mean recall times were significantly extended in patients who were dosed by the practice DSS through the full 12 months (24 days to 36 days) (P = 0.033). Adverse events were comparable between hospital and practice-dosed patients, although a number of esoteric events occurred. Patient satisfaction with the practice clinics was high. CONCLUSION: Computerized DSS enables the safe and effective transfer of anticoagulation management from hospital to primary care and may result in improved patient outcome in terms of the level of control, frequency of review and general acceptability.

Increasing the number of drugs available over the counter: arguments for and against.

Many drugs previously restricted to prescription only status are being reclassified as pharmacy only status and hence are becoming available over the counter to patients. A general practitioner should make enquiries about a patient's self-medication practices before deciding on treatment for the patient. Over-the-counter medicines are considered safe and their increased use indicates that patients are taking greater responsibility for their own health and possibly taking some of the financial burden of drug treatment from the National Health Service. The retention of their restriction to pharmacy only sale provides some additional protection for patients and promotes the role of pharmacists in the care of patients. However, having more drugs available for self-treatment may encourage patients to believe that there is a drug treatment for every ailment. Increasing the range of drugs available over the counter increases the risks of interactions and adverse reactions and of self-treatment being undertaken when medical aid should have been sought. For general practitioners to recommend positively use of over-the-counter preparations may involve some medicolegal risks, and the potential savings to the NHS may prove illusory. Education for patients and better communication between general practitioners and community pharmacists are required to allow easier availability of modern medicines to patients in order to bring the benefits anticipated.

Factors which influence the decision whether or not to prescribe: the dilemma facing general practitioners.

In this study of the influences affecting general practitioners' decisions whether or not to prescribe, 69 principals and five trainees in general practice were asked about the factors that made these decisions difficult for them and the circumstances in which the decision caused them to feel uncomfortable. Discomfort was reported most frequently in prescribing for respiratory disease, psychiatric conditions and skin problems, though the range of problems mentioned was wide. The range of drugs for which the decision of whether or not to prescribe was difficult was also wide but psychotropic drugs, antibiotics, drugs acting on the cardiovascular system and non-steroidal anti-inflammatory drugs were most often mentioned. Patient factors said to be important included age, ethnicity, social class and education, the doctor's prior knowledge of the patient, the doctor's feeling towards the patient, communication problems, and the doctor's desire to try to preserve the doctor-patient relationship. Doctor specific factors included concerns about drugs, factors relating to doctors' role perception and expectations of themselves, uncertainty, peer influences, logistic factors, and the experience of medical or therapeutic misadventures. The results of this study support earlier work on the influence of social factors on prescribing decisions and show that this influence affects the entire range of clinical problems. The results also reveal the importance of logistic factors. The overriding concern of doctors to preserve the doctor-patient relationship and the range of attitudes, perceptions and experiences of doctors that have a bearing on the decision to prescribe begin to explain the apparent irrationality of some general practitioner prescribing.(ABSTRACT TRUNCATED AT 250 WORDS)