Teaching Safe Prescribing

©2011 Centre for Safe and Effective Prescribing

Safe medication practice tutorials for final year medical

students

Charles Mitchell, Ian Coombes

Centre for Safe and Effective Prescribing, University of Queensland

Medical Education 1900-2000+

• Science based • Problem based • Case based• Systems based, using current (&

hopefully, standardised) processes

Standardisation of Systems

• Means doing the same thing in the same way in the same circumstance. Benefits include: – improvement in safety and efficacy of

systems– increased familiarity when staff rotate– reduction in opportunities for patient harm

• Should be evidence based• Enables effective education and training of

specific tasks and procedures

Adverse drug events (ADE)

• Quality in Australian Healthcare study n=141791

– 1.8% of admissions associated with ADE– 1.1% of QH admissions 2005 associated with

ADE 2

• ADEs: 0.7% - 24.9% per hospital admission• Preventable: 19% - 61%• 52% ADEs associated with prescribing, 11%

with transcribing component of medication3

1: Wilson et al, MJA 1995; 2: QH IDC Report 2005: 3: Bates, JAMA 1995

Hospital admissions – 2000-1

• Angina: 88,500• Myocardial infarction: 37,500• Asthma: 49,000• Diabetes: 46,000

Hospital admissions – 2000-1

• Angina: 88,500• Myocardial infarction: 37,500• Asthma: 49,000• Diabetes: 46,000• Medication-related 140,000


Local issues• Audits and incident analyses showed most

interns made prescribing errors most weeks• Evaluation of all recent cohorts of graduating

students indicated that prescribing was their most stressful task

Proposal• Prescribing should be considered in a

similar way to procedures – Where a combination of knowledge and, more

importantly, competencies (skills) are prerequisites to be demonstrated before being allowed to perform a specific complex task

• Main difference - procedures require psychomotor skills in addition to cognitive skills

4 Domains of Prescribing

Enabling Know-ledge

Info Gathering

Clinical Decision Making

Communicate Decision –Prescribe

Monitor & Review

Experience

Feedback

Self -Reflection

Mapping the 4 Domains of Prescribing

• Australia - ACFJD- Good Medical Practice: Code of Conduct for Doctors 2009

• UK - Prescribing Competency Framework (NPC)- Statement of Competencies in Prescribing required by Foundation Doctors (GMC)

• USA – Competency Based Residency Education (ACGME)

• Canada – CanMEDS 2005 Physician Competency Framework

• WHO - Good Prescribing Guidelines

• KC 1: Take and/or review medical and medication history and undertake physical examination and investigations where appropriate

• KC 2: Assess adherence to current and past medication and risk factors for

non-adherence

Info Gathering


• KC 3: Identify the more important health or medication related issue for the patient

• KC 4: Determine how well disease and symptoms are managed/controlled

• KC 5: Determine whether current symptoms are modifiable by symptomatic treatment or disease modifiable treatment

• KC 6: Consider ideal therapy (drug & non-drug)

• KC 7: Select drug, form, route, dose, frequency, duration of treatment

Clinical Decision Making

• KC 8: Communicate prescribing decision in an ambulatory care setting

• KC 9: Communicate prescribing decision in an inpatient setting

Communicate Decision – Prescribe

• KC 10: Review (1) control of symptoms & signs (2) adherence (3) patient's outcomes

Monitor &

Review

Domain • Information gathering

Compe-tency

• Assess adherence to current & past medications and risk factors for non-adherence

Learning

Objec-tives

• Understands the importance of assessing adherence

• Knows the risk factors for non-adherence• Know the evidence for strategies to improve

adherence• Acquires skills for detecting non-adherent behaviour• Acquires skills for encouraging medication

adherence

Assess-ment

• MCQ• OSCEs (Objective Structured Clinical Examination)• Mini Clinical Examination (Mini CEx)

Improving safety of prescribing(Communicating prescribing decision)

• Reduce need for interpretation • Human factor approach to develop

standardised systems• Decision support available• Understanding of safety and risks • Allowing development of skills in

“protected” constructive scenarios

Error prone steps: Prescribing• The correct treatment selection:

– focus on “The Drug” – exacerbated by training (Barber et al, 2003)

– >80% decisions by experienced doctors (Pearson, 1998)

• Generation of the order:– communication: Dr to Dr, RN & pharmacist– 60% junior doctors, majority “transcribing”

• Errors in dose, form, duration, similar ADR


Objectives of StudyTo develop and evaluate a practical, safemedication practice module for final yearmedical studentsTo raise awareness of risks associated with

medication management in particular prescribing

To improve confidence and ability to prescribe safely and effectively when interns.

MethodStudents (90) at intervention site (PAH)

attended • 8 tutorials• Delivered by pharmacy, medical and

nursing staff.

Students (143) attending other sites were a parallel control group.

Content of the program1. Human error and incident analysis2. Medication history taking & confirmation3. General prescribing, ADRs & antibiotics4. Anticoagulation 5. Discharge medication; continuum of care6. Fluids and electrolytes 7. Insulin and BGL management8. Analgesics and narcotics

Focus of program

• NOT pharmacology/ therapeutics lecture(s)• To raise awareness of risks in medication

management system• To introduce students to the mechanism of

safely communicating treatment decisions to “the team”

• To develop skills in history taking, prescribing

• To introduce to basic principles around prescribing of key high risk medications

High Risk Medications

• Potassium and concentrated electrolytes• Insulin and oral hypoglycaemics• Narcotics• Cytotoxics• Heparin & warfarin• Antibiotics (aminoglycosides and penicillin allergy)

• Analgesics & NSAIDsWilson, MJA 1995; Leape, JAMA 1995; Dean, Lancet 2002


Intervention: • Involve errors and near misses• Prescribing scenarios, cases and

problems• Limited theory on therapeutics • Reviewing and utilising each others

work• Deliver key messages

Qualitative feedback on course

• Innovative, interactive, relevant and useful• Important information not previously

covered in their MBBS curriculum• Should be mandatory and occur earlier in

the course, over a longer period of time• Hands-on nature of the course most

effective• Raises profile of medication safety and

error awareness

0

20

40

60

80

100

Iv fluid electrolytes Insulin

%

Control Intervention

Trainee interns’ prescribing confidence(2005, Control = 48, Intervention = 40)

Trainee interns’ prescribing confidence(2005, Control = 48, Intervention = 40)

020406080

100

Nurses admin "simpletherapy"

Warfarin Discharge

%


Final Exam September (2004 + 2005)Summative Assessment

4 questions over 40 minute 1) identify risk of re-exposure heart failure

patient to ACE-I 2) Prescribe 5 medications, various “traps’3) Assess risks and benefits warfarin4) Ward call – acute gout management

Question Mean control (n= 143)

Mean intervention

(n=90)

Max Sig (T test 2 tailed)

ADR 4.22 4.94 6 0.01

Prescribing(Errors)

11.30(2.70)

12.52(1.48)

14 0.00

Warfarin 4.50 4.98 7 0.011

NSAIDs 6.33 7.02 11 0.041

Sum 26.28 29.49 38 <0.05


Measures of prescribing safetyin intern orders

(N= 430 intervention vs 435 control orders)

ADR DOCUMENTATIONn % n %

ADR documented: 71 76 70 91N of ADR 43 45ADR Rxn documented 23 53 33 73


Y4: 2004; Interns: 2005

ConclusionsThis pharmacist-lead program has been well

received and has demonstrated an increased medical students’ confidence and ability to prescribe safely and effectively in common situations that they will encounter as interns when compared with the control students.

Roll-out and Evaluation of Safe Prescribing Course

• Package complete with facilitator’s notes, handouts, scenarios, model answers and video vignettes.

• Course coordinators should be sought at each site, with a designated clinical pharmacist an essential part of the team.

• CSEP will update material content – sites to copy handouts, worked examples.

• Supplemented by web-based tutorials.• Recommend students access NPS

modules

What’s new• VOPPs

– Total of 8– On Blackboard– Essential viewing prior to tutes (except 1)

• More hands-on exercises and time for interaction

• Trialled at PAH during latter terms of 2010

Assessment at UQ

• The content of this course assessed by end of year summative MSAT station(s)

• Possibility of end of rotation (term) written assessment.

• Ideally, should include a portfolio.


Which Years and How delivered?

• Will introduce the course in Year III when students first exposed to practical medicines management.

• Consider having some of the basic and introductory sessions immediately before clinical rotations (ie, end of Year 2)

Fluid & electrolytes: VOPP• Fluid compartments• Destination of infused fluids• Fluid requirements• Electrolyte requirements• Assessment of fluid status• Available IV fluids • “Standard” patient fluids• Electrolyte abnormalities• IV Fluids Chart

May prescribe fluids for 24 hr

Chart must be reviewed every day

Prescribing in patients with diabetes – insulin and hypoglycaemic agents

Presented by Charles MitchellCentre for Safe and Effective

Prescribing

©2011 CSEP

Material covered• Benefits and risks of glycaemic

control• Overview of therapies

– OHG– injectable hypoglycaemics– insulin

• Insulin forms– subcut– intravenous

Introducing the IV insulin chart


Patient Sticker Joan Smith Communication by DrBGL monitoring frequencySpecial instructionsTarget range

AlertshyperglycemiaMonitoring

Completed by Nursing StaffBGL readingsCreates a “graph”

AdministrationCompleted by Nursing StaffInsulin infusion rate, bolusesNotifications made

PrescribingCompleted by DoctorInsulin infusion rate, boluses

Recommended Insulin infusion rate

Alertshypoglycemia

Intravenous (IV) Insulin Sliding Scale

• Usual target BGL ~ 5.1-10 mmol/L• Most patients need ~ 1-2 units/hour

• Must monitor frequently (hourly BGL)• Never use u (units) & no terminal zero – may lead to 10 x

error!• order sufficient insulin for 24 hours• must order glucose IV co-infusion

(to run through same line as insulin)• BGLs MUST be measured hourly in most patients;

occasionally, 2nd hourly OK

Changing from IV to Sub-Cut Insulin• Return patient to normal regimen ASAP• Calculate total daily insulin used via

infusion (remember the patient likely to have been fasting;– or use 0.4 units per kg

• Administer short/rapid acting insulin sub-cut 1-2 hours before discontinuing IV & intermediate/long acting insulin 2-3 hours before discontinuing IV

Introducing the subcut insulin chart

Decision Support

Recommended Supplemental InsulinNo Previous Insulin


Decision Support

Recommended Supplemental InsulinOn Previous Insulin

Joan Smith

Communication by DrBGL monitoring frequencySpecial instructionsTarget range

Joan Smith

Monitoring and AdministrationCompleted by Nursing StaffBGL readingsInsulin administration recordCreates a “graph”

Further Reading

Incretins (Byetta): NPS RADARIncretins (Byetta): NPS RADAR

Gliptins: NPS RADARGliptins: NPS RADAR

Incretins: Australian PrescriberIncretins: Australian Prescriber

NPS News 56: Managing Hyperglycemia in Type II DiabetesNPS News 56: Managing Hyperglycemia in Type II Diabetes

Remember to bring a subcut insulin chart and an intravenous insulin chart to the tutorial

Prescribing Exercise• Deborah Parker (63yrs) is admitted to your

ward from outpatients with a diabetes related gangrene right 5th toe and foot

• She has a 15 year history of Type 2 Diabetes, now treated with insulin and metformin

• White cell count is elevated• She is to commence IV antibiotics in

preparation of surgical intervention


What do you need to know?• Current insulin regimen

and doses

• Current metformin doses

• Humalog 14 units with breakfast, 18 units with lunch, 12 units with dinner

• Lantus 35 units before bed

• 1gram twice daily

Now write up the chart• Write up Routine doses for the next 24 hours• It is the 8/10/10 at 12 midday

– Humalog 14 units with breakfast, – 18 units with lunch, – 12 units with dinner– Lantus 35 units before bed

• And write Insulin Type/s in Admin Record• Not for supplemental insulin at the moment• BGL on admission (12 midday) is 10.2 mmol/L

• Now lunch time and Deborah’s meal has arrived• Administer and document lunchtime insulin dose

The next day……• BGLs have been elevated since yesterday, with a

spike at midday• Record the following BGLs

– 8/10 1730 14.7– 8/10 2130 12.5– 9/10 0730 14.9 What action is required?– 9/10 1200 19.7

• You were notified of the elevated BGLs and have now arrived on the ward round to review Deborah and order the next doses


Guidelines Page

• Go to bottom of Column B– ‘Patients PREVIOUSLY on INTENSIVE insulin

treatment’

• BGLs are elevated more than 4 hours after meal time insulin

• Increase Lantus by 20% =?? Units• Add mealtime supplemental insulin to

cover while adjusting Lantus• Use Table 2 to determine Supplemental

doses

Intern Survey - 2010 • Surveyed 116 interns

– PAH (n=34) – 76% UQ– RBWH (n=57) – 66% UQ– GCH (n=25) – 48% GU; 24% Interstate/Other

• Standard tool• List of topics

– Essential, Desirable, Optional, Not needed

Essential + Desirable Topics (%) - 1

Essential + Desirable Topics (%) - 2


Methods

• Vincent’s Incident Analysis Protocol• 2 senior pharmacists and consultant

doctor– Independent analysis of transcripts – Identified factors and underlying

themes– Considered possible solutions

• Focus groups with interns x 2, registrars and pharmacists

Results – error descriptions

Admission In ‐patient

Dis‐charge

Dose error

Drug error

Patient error

New prescribing n= 11

2 7 2 5 5 0

Re‐Prescribing n =10

1 2 7 3 6 1

Total n =21

3 9 9 8 11 1

47 - prescribing errors reported21 - anticoagulants or antibiotics21 - errors discussed; 14 prescribers interviewed

Results – underlying factors

Prescribed before

Made error before

Median time as intern (weeks)

New prescribingN=11

4 2 4 (median)

Re‐PrescribingN=10

9 5 8 (median)

TotalN=21 13 7

Results – Underlying factors

FACTORS Environ‐mental

Team Individual Task Patient Median

New prescribing n = 11

9 11 11 7 10 5

Re ‐Prescribing n = 10

9 5 6 9 3 3

Total n =21 18 16 17 18 13

Combination of factors• New-prescribing errors

– Inexperienced interns – Complicated patient– Physical factors– Lack “tailored” supervision

• Re-prescribing errors– Task design– Location of medication chart– PBS system

Clear that no one intervention will prevent

Teaching Safe Prescribing

Documents

Transcript of Teaching Safe Prescribing