Do educational interventions improve prescribing skills of medical students compared to no additional learning? A systematic review.

Research suggests that medical students are not confident and may be ill-prepared to prescribe competently. Therefore, changes to standard education may be required to fortify medical student prescribing skills, confidence, and competence. However, specific education to write a safe and legal prescription is generally lacking. Furthermore, the term prescribe and the skill thereof is not clearly defined. This review compares additional education for medical students to no identified additional education or another educational modality on the skill of prescription writing. Secondary aims include review of education modalities, prescribing skill assessments, educator professional background, and timing of education within the medical curriculum. This systematic review was conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Databases searched included: CINAHL, Cochrane Library, EMBASE, Emcare (Ovid), MEDLINE (Ovid), PubMed and Scopus. Search terms included: medical education, medical undergraduate, medical student, medical school, and prescriptions. The search was conducted in February 2023, and quantitative outcomes were reported. Of the 5197 citations identified, 12 met the inclusion criteria. Eleven studies reported significant improvements in prescribing skills of medical students after additional educational intervention(s). Various educational modalities were implemented, including case-based teaching (n=3), patient-based teaching (n=1), tutorial-based teaching (n=2), didactic teaching (n=1), and mixed methods (n=6). There were no commonalities in the professional background of the educator; however, five studies used faculty members. There was no consensus on the best assessment type and time to implement prescription writing education during medical training. There are a range of interventions to educate and assess prescribing competencies of medical students. Despite heterogenous study designs, there is evidence of the superiority of additional prescription writing education versus no identified additional education to develop prescription writing skills. The introduction of formal teaching and standardised assessment of prescribing skills for medical students is recommended.

Medication reconciliation and discharge communication from hospital to general practice: a quantitative analysis.

BACKGROUND: The aim of this study was to assess the quality of effective discharge communication to primary practice from a hospital that uses ieMR (integrated electronic Medical Record), a complete electronic prescribing/medical record platform. METHODS: A retrospective quantitative analysis of 232 discharge encounters from a major tertiary hospital assessed the discharge summary quality; timeliness, completeness and medication information. RESULTS: Median time to discharge summary was 1day. 22.0% of discharge summaries were incomplete at 30days post discharge and 44.5% of discharge summaries were incomplete at 30days post discharge if discharged on a weekend compared to weekday (P -value=0.001). Rates of medication reconciliation were completed at approximately 35% at each point of the patient stay and 56.9% of patients had a GP discharge summary listing discharge medications. However, if certain progressive steps were completed (i.e. Home Medications recorded in ieMR, Discharge Reconciliation in ieMR, and Patient Discharge Medication Record in eLMs (Enterprise-wide Liaison Medication System)), then, the 'Medications on Discharge' was significantly more likely to be present in the discharge summary, at rates of 70.1%, 85.9%, and 98.6% respectively (P -value=0.007, <0.001, <0.001). Conversely not doing these steps dropped rates of having medications listed in the discharge summary to 50.0%, 40.3% and 34.1% respectively. CONCLUSIONS: This study assessed current discharge summary quality since the introduction of electronic medical records. It demonstrated the significant value of correct use of electronic programs, including performing all crucial steps of reconciliation. Targeted interventions in future studies that rectify the shortfalls in discharge communication are warranted.

Australian general practitioners' views on qualities that make effective discharge communication: a scoping review.

Transitions of patient care between hospital discharge and primary care are known to be an area of high-risk where communication is imperative for patient safety. Discharge summaries are known to often be incomplete, delayed and unhelpful for community healthcare providers. The aim of this review was to identify and map the literature which discusses Australian general practitioners' (GPs) views on the qualities that make up effective discharge communication. Medline, Scopus and the Cochrane register of controlled drug trails and systematic reviews were searched for publications until October 2021 that discussed Australian GPs' views on discharge communication from hospital to general practice. Of 1696 articles identified, 18 met inclusion and critical appraisal criteria. Five studies identified that GPs view timeliness of discharge summary receipt to be a problem. Communication of medication information in the discharge summary was discussed in six studies, with two reporting that GPs view reasons for medication changes to be essential. Five studies noted GPs would prefer to receive clinical discipline or diagnosis specific information. Four studies identified that GPs viewed the format and readability of discharge summaries to be problematic, with difficulties finding salient information. The findings of this scoping review indicate that GPs view timeliness, completeness, readability, medication related information and diagnosis/clinical discipline specific information to be qualities that make up effective discharge communication from hospital to the community. There are opportunities for further research in perspectives of effective discharge communication, and future studies on interventions to improve discharge communication, patient safety and policy in transfers of care.

Pharmacist-Led Education for Final Year Medical Students: A Pilot Study.

Background: Prescribing is a core skillset for medical officers. Prescribing errors or deficiencies can lead to patient harm and increased healthcare costs. There is an undefined role for pharmacist-led education to final year medical students to improve prescribing skills. Aim: Assess if pharmacist-led education on prescription writing improves the quality and safety of final year medical students' prescribing skills. Method:  Participants and Intervention: Final year medical students were randomised into tutorial (TG) or non-tutorial groups (NTG) and assessed pre- and post- intervention. TG received education by a clinical pharmacist and pharmacy educator using case-based learning. NTG received no additional training as per usual practice. Following the pre-test, all students completed a 3-week tertiary hospital medical ward placement. Students completed the post-test following placement and after the TG participated in the intervention. Student Assessment: Assessment included writing Schedule 4 (S4, prescription only), Schedule 8 (S8, controlled drug), S4 streamline (S4SL), and Mixed case (S4 and S8) prescriptions. Results: At baseline, there were no significant differences between TG and NTG for overall scores or proportion of passes. Post intervention scores significantly improved in TG (p = 0.012) whereas scores significantly decreased in the NTG (p = 0.004). The overall proportion of passes was significantly higher in the TG than NTG (p < 0.001). Conclusion: Education by a clinical pharmacist improved short-term prescribing skills of final year medical students in this study. Students learning primarily experientially from peers and rotational supervisors showed decreased prescribing skills. We propose pharmacist-led education on prescription writing should be further evaluated in larger studies across more student cohorts and for longer periods of follow up time to clarify whether such an educational model could be included in future medical school curricula.

Infrastructure and operating processes of PIONEER, the HDR-UK Data Hub in Acute Care and the workings of the Data Trust Committee: a protocol paper.

INTRODUCTION: Health Data Research UK designated seven UK-based Hubs to facilitate health data use for research. PIONEER is the Hub in Acute Care. PIONEER delivered workshops where patients/public citizens agreed key principles to guide access to unconsented, anonymised, routinely collected health data. These were used to inform the protocol. METHODS: This paper describes the PIONEER infrastructure and data access processes. PIONEER is a research database and analytical environment that links routinely collected health data across community, ambulance and hospital healthcare providers. PIONEER aims ultimately to improve patient health and care, by making health data discoverable and accessible for research by National Health Service, academic and commercial organisations. The PIONEER protocol incorporates principles identified in the public/patient workshops. This includes all data access requests being reviewed by the Data Trust Committee, a group of public citizens who advise on whether requests should be supported prior to licensed access. ETHICS AND DISSEMINATION: East Midlands-Derby REC (20/EM/0158): Confidentiality Advisory Group (20/CAG/0084). www.PIONEERdatahub.co.uk.

Systematic review of stability data pertaining to selected antibiotics used for extended infusions in outpatient parenteral antimicrobial therapy (OPAT) at standard room temperature and in warmer climates.

Aim: To determine if there are sufficient stability data to confirm appropriate prescribing of antibiotics commonly used in outpatient parenteral antimicrobial therapy (OPAT) in warmer climates. Data sources: Four databases were systematically searched using the terms 'beta-lactams', or 'antibiotics', or 'anti-bacterial agents' and 'drug stability' or drug storage' for studies specific to drug stability published between 1966 and February 2018. Study selection: The search strategy initially identified 2879 potential articles. After title and abstract review, the full-texts of 137 potential articles were assessed, with 46 articles matching the inclusion and exclusion criteria included in this review. Results: A large volume of stability data is available for the selected drugs. Stability data at temperatures higher than 25°C were available for several of the medications, however few drugs demonstrated stability in warmer climates of 34°C or higher. Only buffered benzylpenicillin, cefoxitin and buffered flucloxacillin were found to have stability data supporting OPAT in warmer climates. Sequential data, profiling the drug for an extended period in solution under refrigeration prior to the run-out period at the higher temperatures, are also lacking. Limitations: This study was limited by including only peer reviewed articles. There may be further grey literature supporting the stability of some of the drugs mentioned. Conclusion: There are insufficient stability data of antibiotic use in warmer climates. Studies to verify the stability and appropriate use of many antibiotics used in OPAT at standard room temperature and in warmer climates are urgently required. Several drugs in current use in the OPAT settings are lacking stability data. Implications: Further research in this field is needed to develop structured evidence-based guidelines. Results of this review should be further compared with observed patient outcomes in current clinical practice.

A systematic review of clinical pharmacist interventions in paediatric hospital patients.

Clinical pharmacists provide beneficial services to adult patients, though their benefits for paediatric hospital patients are less defined. Five databases were searched using the MeSH terms 'clinical pharmacist', 'paediatric/paediatric', 'hospital', and 'intervention' for studies with paediatric patients conducted in hospital settings, and described pharmacist-initiated interventions, published between January 2000 and October 2017. The search strategy after full-text review identified 12 articles matching the eligibility criteria. Quality appraisal checklists from the Joanna Briggs Institute were used to appraise the eligible articles. Clinical pharmacist services had a positive impact on paediatric patient care. Medication errors intercepted by pharmacists included over- and under-dosing, missed doses, medication history gaps, allergies, and near-misses. Interventions to address these errors were positively received, and implemented by physicians, with an average acceptance rate of over 95%. Clinical pharmacist-initiated education resulted in improved medication understanding and adherence, improved patient satisfaction, and control of chronic medical conditions.Conclusion: This review found that clinical pharmacists in paediatric wards may reduce drug-related problems and improve patient outcomes. The benefits of pharmacist involvement appear greatest when directly involved in ward rounds, due to being able to more rapidly identify medication errors during the prescribing phase, and provide real-time advice and recommendations to prescribers. What is Known: • Complex paediatric conditions can require multiple pharmaceutical treatments, utilised in a safe manner to ensure good patient outcomes • The benefits of pharmacist interventions when using these treatments are well-documented in adult patients, though less so in paediatric patients What is New: • Pharmacists are adept at identifying and managing medication errors for paediatric patients, including incorrect doses, missed doses, and gaps in medication history • Interventions recommended by pharmacists are generally well-accepted by prescribing physicians, especially when recommendations can be made during the prescribing phase of treatment.

An assessment of the performance of the Baxter elastomeric (LV10) Infusor™ pump under hyperbaric conditions.

INTRODUCTION: There are limited data on the use of elastomeric infusion pumps during hyperbaric oxygen treatment. AIM: This study evaluated the flow rate of the Baxter elastomeric LV10 Infusor™ pump under normobaric (101.3 kPa) and three hyperbaric conditions of 203 kPa, 243 kPa and 284 kPa. METHODS: Elastomeric pumps were secured to participants in the same manner as for a typical patient, except that a container collected the delivered antibiotic solution. Pumps and tubing were weighed before and after the test period to determine volume delivered and to calculate flow rates at sea level and the three commonly used hyperbaric treatment pressures at two different time periods, 0-2 hours (h) and 19-21 h into the infusion. RESULTS: The mean flow rates in ml·h⁻¹ (SD) were: 9.5 (0.4), 10.3 (0.6), 10.4 (0.6), 10.4 (0.5) at 0-2 h and 10.5 (1.0), 12.2 (0.6), 9.4 (0.5), 10.3 (0.9) at 19-21 h for the normobaric, 203 kPa, 243 kPa and 284 kPa conditions respectively. There was no significant association between flow rate and time period (P = 0.166) but the 203 kPa flow rates were significantly faster than the other flow rates (P = 0.008). In retrospect, the 203 kPa experiments had all been conducted with the same antibiotic solution (ceftazidime 6 g). Repeating that experimental arm using flucloxacillin 8 g produced flow rates of 10.4 (0.8) ml·h⁻¹, with no significant associations between flow rate and time period (P = 0.652) or pressure (P = 0.705). CONCLUSION: In this study, the flow rate of the Baxter LV10 Infusor™ device was not significantly affected by increases in ambient pressure across the pressure range of 101.3 kPa to 284 kPa, and flow rates were generally within a clinically acceptable range of 9-12 ml·h⁻¹. However, there was evidence that the specific antibiotic solution might affect flow rates and this requires further study.

Clozapine repackaged into dose administration aids: a common practice in Australian hospitals.

OBJECTIVES: Clozapine is an atypical antipsychotic used in the treatment of schizophrenia. Due to the patient profile there is a high rate of repackaging of clozapine into dose administration aids (DAAs). Because of reports from hospital pharmacists about discoloration of returned clozapine tablets that have been repackaged into DAAs, the aim of this study was to evaluate the chemical, physical and photostability of these tablets repackaged into a DAA. METHOD: Clozapine tablets were repackaged into DAAs and evaluated for physicochemical stability over a 6-week period at a controlled room temperature (25±1°C; 60±1.5% relative humidity (RH)) and accelerated conditions (40±1°C; 75±1.5% RH). In addition, photostability studies were performed according to the International Committee on Harmonisation (ICH) guidelines. KEY FINDINGS: Chemical stability was confirmed for all storage conditions, including for those photostability (ICH conditions), with the clozapine content occurring within the British Pharmacopoeial (BP) range of 90-110%. Although the physical stability was confirmed for all tests at room temperature (weight uniformity, hardness, friability, disintegration and dissolution), under accelerated conditions the disintegration test did not meet BP requirements. However, the subsequent dissolution test was successful with 85% of clozapine dissolving in 45min. CONCLUSIONS: This study illustrates that clozapine, when correctly repackaged, maintains its physical and chemical stability for 6 weeks. As no discoloration of the tablets was observed, it is assumed that the reports received were as a result of improper handling by patients. Based on these findings, it is recommended that patients be advised on the correct handling and storage of their DAAs.