Prevalence and Causes of Prescribing Errors: The PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) Study

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Abstract

Objectives

Study objectives were to investigate the prevalence and causes of prescribing errors amongst foundation doctors (i.e. junior doctors in their first (F1) or second (F2) year of post-graduate training), describe their knowledge and experience of prescribing errors, and explore their self-efficacy (i.e. confidence) in prescribing.

Method

A three-part mixed-methods design was used, comprising: prospective observational study; semi-structured interviews and cross-sectional survey. All doctors prescribing in eight purposively selected hospitals in Scotland participated. All foundation doctors throughout Scotland participated in the survey. The number of prescribing errors per patient, doctor, ward and hospital, perceived causes of errors and a measure of doctors' self-efficacy were established.

Results

4710 patient charts and 44,726 prescribed medicines were reviewed. There were 3364 errors, affecting 1700 (36.1%) charts (overall error rate: 7.5%; F1:7.4%; F2:8.6%; consultants:6.3%). Higher error rates were associated with : teaching hospitals (p<0.001), surgical (p = <0.001) or mixed wards (0.008) rather thanmedical ward, higher patient turnover wards (p<0.001), a greater number of prescribed medicines (p<0.001) and the months December and June (p<0.001). One hundred errors were discussed in 40 interviews. Error causation was multi-factorial; work environment and team factors were particularly noted. Of 548 completed questionnaires (national response rate of 35.4%), 508 (92.7% of respondents) reported errors, most of which (328 (64.6%) did not reach the patient. Pressure from other staff, workload and interruptions were cited as the main causes of errors. Foundation year 2 doctors reported greater confidence than year 1 doctors in deciding the most appropriate medication regimen.

Conclusions

Prescribing errors are frequent and of complex causation. Foundation doctors made more errors than other doctors, but undertook the majority of prescribing, making them a key target for intervention. Contributing causes included work environment, team, task, individual and patient factors. Further work is needed to develop and assess interventions that address these.

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Most cited references 8

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Causes of prescribing errors in hospital inpatients: a prospective study.

HOWARD M. SCHACHTER, Charles A Vincent, Nick Barber … (2002)

To prevent errors made during the prescription of drugs, we need to know why they arise. Theories of human error used to understand the causes of mistakes made in high-risk industries are being used in health-care. They have not, however, been applied to prescribing errors, which are a great cause of patient harm. Our aim was to use this approach to investigate the causes of such errors. Pharmacists at a UK teaching hospital prospectively identified 88 potentially serious prescribing errors. We interviewed the prescribers who made 44 of these, and analysed our findings with human error theory. Our results suggest that most mistakes were made because of slips in attention, or because prescribers did not apply relevant rules. Doctors identified many risk factors-work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. Organisational factors were also identified, and included inadequate training, low perceived importance of prescribing, a hierarchical medical team, and an absence of self-awareness of errors. To reduce prescribing errors, hospitals should train junior doctors in the principles of drug dosing before they start prescribing, and enforce good practice in documentation. They should also create a culture in which prescription writing is seen as important, and formally review interventions made by pharmacists, locum arrangements, and the workload of junior doctors, and make doctors aware of situations in which they are likely to commit errors.

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What is a prescribing error?

HOWARD M. SCHACHTER, Glen N. Barber, Jay B. Dean (2000)

To develop a practitioner led definition of a prescribing error for use in quantitative studies of their incidence. Two stage Delphi technique. A panel of 34 UK judges, which included physicians, surgeons, pharmacists, nurses and risk managers. The extent to which judges agreed with a general definition of a prescribing error, and the extent to which they agreed that each of 42 scenarios represented a prescribing error. Responses were obtained from 30 (88%) of 34 judges in the first Delphi round, and from 26 (87%) of 30 in the second round. The general definition of a prescribing error was accepted. The panel reached consensus that 24 of the 42 scenarios should be included as prescribing errors and that five should be excluded. In general, transcription errors, failure to communicate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors; deviations from policies or guidelines were not. Health care professionals are in broad agreement about the types of events that should be included and excluded as prescribing errors. A general definition of a prescribing error has been developed, together with more detailed guidance regarding the types of events that should be included. This definition allows the comparison of prescribing error rates among different prescribing systems and different hospitals, and is suitable for use in both research and clinical governance initiatives.

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Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review.

Joel P. Tully, Val Wass, Frances M. Ashcroft … (2009)

Prescribing errors affect patient safety throughout hospital practice. Previous reviews of studies have often targeted specific populations or settings, or did not adopt a systematic approach to reviewing the literature. Therefore, we set out to systematically review the prevalence, incidence and nature of prescribing errors in hospital inpatients. MEDLINE, EMBASE, CINAHL and International Pharmaceutical Abstracts (all from 1985 to October 2007) were searched for studies of prescriptions for adult or child hospital inpatients giving enough data to calculate an error rate. Electronic prescriptions and errors for single diseases, routes of administration or types of prescribing error were excluded, as were non-English language publications. Median error rate (interquartile range [IQR]) was 7% (2-14%) of medication orders, 52 (8-227) errors per 100 admissions and 24 (6-212) errors per 1000 patient days. Most studies (84%) were conducted in single hospitals and originated from the US or UK (72%). Most errors were intercepted and reported before they caused harm, although two studies reported adverse drug events. Errors were most common with antimicrobials and more common in adults (median 18% of orders [ten studies, IQR 7-25%]) than children (median 4% [six studies, IQR 2-17%]). Incorrect dosage was the most common error. Overall, it is clear that prescribing errors are a common occurrence, affecting 7% of medication orders, 2% of patient days and 50% of hospital admissions. However, the reported rates of prescribing errors varied greatly and this could be partly explained by variations in the definition of a prescribing error, the methods used to collect error data and the setting of the study. Furthermore, a lack of standardization between severity scales prevented any comparison of error severity across studies. Future research should address the wide disparity of data-collection methods and definitions that bedevils comparison of error rates or meta-analysis of different studies.

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Author and article information

Contributors

Heiner K. Berthold: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2014

Publication date (Electronic): 3 January 2014

Volume: 9

Issue: 1

Electronic Location Identifier: e79802

Affiliations

[1 ]School of Pharmacy, Queen's University Belfast, Belfast, United Kindgom

[2 ]School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom

[3 ]School of Medicine, University of Dundee, Dundee, United Kingdom

[4 ]Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom

[5 ]Health Services Research and Management Division, City University London, London, United Kingdom

[6 ]Medical Statistics Team, University of Aberdeen, Aberdeen, United Kingdom

[7 ]Health Psychology, University of Aberdeen, Aberdeen, United Kingdom

[8 ]Clinical Pharmacology Unit, University of Edinburgh, Edinburgh, United Kindgom

[9 ]Department of Clinical Pharmacology, Glasgow Royal Infirmary, Glasgow, United Kindgom

[10 ]Clinical Pharmacology Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kindgom

[11 ]Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom

Charité University Medicine Berlin, Germany

Author notes

* E-mail: c.m.bond@ 123456abdn.ac.uk

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: CR SR PD ED JJF MJ JK AJL MJM SM GAM JSM DJW CB. Performed the experiments: CR SR PD JK SM GAM JSM DJW CB. Analyzed the data: CR SR PD ED JJF SF MJ JK AJL MJM SM GAM JSM DJW CB. Contributed reagents/materials/analysis tools: CR SR PD ED JJF SF MJ JK AJL MJM SM GAM JSM DJW CB. Wrote the paper: CR SR PD ED JJF SF MJ JK AJL MJM SM GAM JSM DJW CB.

Article

Publisher ID: PONE-D-13-18651

DOI: 10.1371/journal.pone.0079802

PMC ID: 3880263

PubMed ID: 24404122

SO-VID: d43c25da-bfe2-49a2-b638-cbe977c83b8a

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 8 May 2013

Date accepted : 25 September 2013

Page count

Pages: 9

Funding

This project was funded by the Scottish Chief Scientists Office. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Prevalence and Causes of Prescribing Errors: The PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) Study

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Abstract

Objectives

Method

Results

Conclusions

Related collections

PLOS Climate

Most cited references 8

Causes of prescribing errors in hospital inpatients: a prospective study.

What is a prescribing error?

Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review.

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