Providing feedback to junior doctors on prescribing errors

Project summary

Background

Hospital doctors receive little feedback on their prescribing errors and often remain unaware of having made them. A key barrier to providing feedback is that hospital pharmacists are often unable to identify prescribers from their signature alone.

This work built on our previous work on prescribing errors and the role of feedback.  We aimed to increase the proportion of prescribers who could be identified from their prescriptions and enhance the provision of feedback on prescribing errors by pharmacists to facilitate learning, reflection and changes to practice, thus increasing the safety of prescribing.

Our objective was to reduce prescribing errors by introducing three linked interventions: improved prescriber identification through a local awareness campaign and provision of name-stamps for junior doctors; principles of effective feedback to support pharmacists to feedback to doctors on individual prescribing errors; and fortnightly prescribing advice emails that addressed a common and/or serious error.

The initial scope spanned 33 doctors and 35 pharmacists based at one hospital site within Imperial College Healthcare NHS Trust. Following an initial local evaluation (Reynolds et al., BMJQualSaf 2015), this was successfully rolled out to all acute hospitals within our Academic Health Science Network. As part of the model, a toolkit was produced and made available via the NIHR Imperial PSTRC and Health Foundation websites to aid other organisations in adopting the approach, as well as a video documentary (see below).

Outcomes

1. Reynolds et al., BMJQualSaf 2015

Resources

 

Play video